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Perreault S, Boivin Proulx LA, Brouillette J, Jarry S, Dorais M. Antipsychotics and Risks of Cardiovascular and Cerebrovascular Diseases and Mortality in Dwelling Community Older Adults. Pharmaceuticals (Basel) 2024; 17:178. [PMID: 38399393 PMCID: PMC10892683 DOI: 10.3390/ph17020178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
This study aims to investigate the effect of antipsychotic agents on cardiovascular and cerebrovascular diseases (CVD/CEV) and mortality risks in the older population living in a community. A cohort of 42,650 new users of antipsychotic agents was built using Quebec healthcare databases (1998-2011). The outcomes were CVD/CEV and mortality incidence in 5 years of follow-up in the total cohort, sub-cohort of patients with no schizophrenia/dementia, sub-cohort with schizophrenia, and sub-cohort with dementia. Comparisons were made between the new users who continued the treatment (adherent level ≥ 60%) vs. those ceasing treatment (adherence level < 60%) using inverse probability of treatment weighting and Cox models. Comparing high adherence vs. low levels, CVD/CEV risk was increased by 36% in the sub-cohort with schizophrenia for atypical antipsychotic users and by 25% in the sub-cohort with dementia for typical antipsychotic users. An increasing mortality risk of 2- to 3-fold was linked with the typical antipsychotic use in all cohorts except the sub-cohort with schizophrenia; in addition, mortality risk is linked with the use of high vs. low doses. Antipsychotics were not linked with CVD/CEV risk, except for atypical antipsychotics in patients with schizophrenia and typical antipsychotics in patients with dementia. The mortality risk was linked with the use of typical antipsychotics and the dose used.
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Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3C 3J7, Canada
- Centre de Recherche en Santé Publique (CReSP), Partenaire CIUSSS du Centre-Sud-de-l’Île-de-Montréal et l’Université de Montréal, Montreal, QC H3L 1M3, Canada
| | - Laurie-Anne Boivin Proulx
- Department of Cardiology, Faculty of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
| | - Judith Brouillette
- Department of Psychiatry and Addictology, Université de Montréal, Montreal, QC H3L 1M3, Canada;
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC H3L 1M3, Canada;
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l’Île-Perrot, QC H3L 1M3, Canada;
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Wang S, Temkin-Greener H, Conwell Y, Cai S. Policy to Reduce Antipsychotic Use and Hospitalization of Nursing Home Residents With Dementia. J Am Med Dir Assoc 2020; 21:1617-1622.e3. [PMID: 32527648 DOI: 10.1016/j.jamda.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Following the 2012 launch of the National Partnership to Improve Dementia Care in Nursing Homes (the National Partnership), the use of antipsychotics has declined. However, little is known about the impact of this effort on quality of care and outcomes for nursing home (NH) residents with Alzheimer's disease and related dementia (ADRD). The objective of this study is to examine changes in hospitalizations for NH long-stay residents with ADRD after the launch of the National Partnership. DESIGN Observational cross-sectional study. SETTING/PARTICIPANTS NH residents who were newly admitted into NHs and became long-stay residents between January 2011 and March 2015 (n = 565,885). METHODS We estimated linear probability models to explore the relationship between the National Partnership and the likelihood of NH-originated hospitalizations for NH long-stay residents with ADRD, accounting for facility fixed effect, individual covariates, and concurrent changes in hospitalizations among residents without ADRD. We further stratified the analysis by NHs according to their prevalence of antipsychotic use at baseline (ie, prior to the National Partnership). RESULTS We detected a 0.7-percentage point relative increase (P value <.01) in risk-adjusted probabilities of hospitalizations among residents with ADRD compared with non-ADRD residents in the post-Partnership period. In the stratified analysis, we detected a 1.2-percentage point increase (P = .037) in the probability of hospitalizations among ADRD residents in NHs with high antipsychotic use at baseline but no significant change among those in NHs with low antipsychotic use. CONCLUSIONS AND IMPLICATIONS Although the National Partnership may have reduced exposure to antipsychotics, our findings suggest this was related to an increase in hospitalization risk for residents with ADRD. Further research is needed to elucidate the reasons behind the observed relationship and to examine the impact of the National Partnership on other health outcomes.
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Affiliation(s)
- Sijiu Wang
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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3
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Forbes H, Douglas I, Finn A, Breuer J, Bhaskaran K, Smeeth L, Packer S, Langan SM, Mansfield KE, Marlow R, Whitaker H, Warren-Gash C. Risk of herpes zoster after exposure to varicella to explore the exogenous boosting hypothesis: self controlled case series study using UK electronic healthcare data. BMJ 2020; 368:l6987. [PMID: 31969318 PMCID: PMC7190015 DOI: 10.1136/bmj.l6987] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the magnitude and duration of any hypothesised protective effect of household exposure to a child with varicella on the relative incidence of herpes zoster in adults. DESIGN Self controlled case series. SETTING UK general practices contributing to Clinical Practice Research Datalink. PARTICIPANTS 9604 adults (≥18 years) with a diagnosis of herpes zoster (in primary care or hospital records) between 1997 and 2018, who during their observation period lived with a child (<18 years) with a diagnosis of varicella. MAIN OUTCOME MEASURES Relative incidence of herpes zoster in the 20 years after exposure to a child with varicella in the household compared with baseline time (all other time, excluding the 60 days before exposure). RESULTS 6584 of the 9604 adults with herpes zoster (68.6%) were women. Median age of exposure to a child with varicella was 38.3 years (interquartile range 32.3-48.8 years) and median observation period was 14.7 (11.1-17.7) years. 4116 adults developed zoster in the baseline period, 433 in the 60 days before exposure and 5055 in the risk period. After adjustment for age, calendar time, and season, strong evidence suggested that in the two years after household exposure to a child with varicella, adults were 33% less likely to develop zoster (incidence ratio 0.67, 95% confidence interval 0.62 to 0.73) compared with baseline time. In the 10-20 years after exposure, adults were 27% less likely to develop herpes zoster (0.73, 0.62 to 0.87) compared with baseline time. A stronger boosting effect was observed among men than among women after exposure to varicella. CONCLUSIONS The relative incidence of zoster was lower in the periods after exposure to a household contact with varicella, with modest but long lasting protective effects observed. This study suggests that exogenous boosting provides some protection from the risk of herpes zoster, but not complete immunity, as assumed by previous cost effectiveness estimates of varicella immunisation.
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Affiliation(s)
- Harriet Forbes
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
| | - Ian Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
| | - Adam Finn
- Bristol Children's Vaccine Centre, Schools of Population Health Sciences and of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Judith Breuer
- UCL Division of Infection and Immunity Wing 1.3, London, UK
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
| | - Simon Packer
- Field Epidemiology Services, Public Health England Bristol, Bristol, UK
| | - Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
| | - Kathryn E Mansfield
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
| | - Robin Marlow
- Bristol Children's Vaccine Centre, Schools of Population Health Sciences and of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Heather Whitaker
- Statistics, Modelling and Economics Department, Data and Analytical Sciences, National Infection Service, Public Health England Colindale, London, UK
| | - Charlotte Warren-Gash
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
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Zivkovic S, Koh CH, Kaza N, Jackson CA. Antipsychotic drug use and risk of stroke and myocardial infarction: a systematic review and meta-analysis. BMC Psychiatry 2019; 19:189. [PMID: 31221107 PMCID: PMC6585081 DOI: 10.1186/s12888-019-2177-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 06/05/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The effect of antipsychotic (AP) drugs on risk of stroke and myocardial infarction (MI) remains unclear due to methodological limitations of, and inconsistencies across, existing studies. We aimed to systematically review studies reporting on the associations between AP drug use and stroke or MI risk, and to investigate whether associations differed among different sub-populations. METHODS We searched Medline, EMBASE, PsychINFO and Cochrane Library (from inception to May 28, 2017) for observational studies reporting on AP drug use and MI or stroke occurrence. We performed random-effects meta-analyses for each outcome, performing sub-groups analyses by study population - specifically general population (i.e. those not restricted to patients with a particular indication for AP drug use), people with dementia only and psychiatric illness only. Where feasible we performed subgroup analyses by AP drug class. RESULTS From 7008 articles, we included 29 relevant observational studies, 19 on stroke and 10 on MI. Results of cohort studies that included a general population indicated a more than two-fold increased risk of stroke, albeit with substantial heterogeneity (pooled HR 2.31, 95% CI 1.13, 4.74, I2 = 83.2%). However, the risk among patients with dementia was much lower, with no heterogeneity (pooled HR 1.16, 95% CI 1.00, 1.33, I2 = 0%) and there was no clear association among studies of psychiatric populations (pooled HR 1.44, 95% CI 0.90, 2.30; substantial heterogeneity [I2 = 78.8])). Associations generally persisted when stratifying by AP class, but few studies reported on first generation AP drugs. We found no association between AP drug use and MI risk (pooled HR for cohort studies: 1.29, 95% CI 0.88, 1.90 and case-control studies: 1.07, 95% CI 0.94, 1.23), but substantial methodological and statistical heterogeneity among a relatively small number of studies limits firm conclusions. CONCLUSIONS AP drug use may be associated with an increased risk of stroke, but there is no clear evidence that this risk is further elevated in patients with dementia. Further studies are need to clarify the effect of AP drug use on MI and stroke risk in different sub-populations and should control for confounding by indication and stratify by AP drug class.
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Affiliation(s)
- Sanja Zivkovic
- 0000 0004 1936 7988grid.4305.2Usher Institute of Population Health Sciences & Informatics, University of Edinburgh, Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX Scotland
| | - Chan Hee Koh
- 0000 0004 1936 7988grid.4305.2College of Medicine and Veterinary Medicine, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB Scotland
| | - Nandita Kaza
- 0000 0004 1936 7988grid.4305.2College of Medicine and Veterinary Medicine, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB Scotland
| | - Caroline A. Jackson
- 0000 0004 1936 7988grid.4305.2Usher Institute of Population Health Sciences & Informatics, University of Edinburgh, Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX Scotland
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Nguyen TA, Pham T, Vu HTT, Nguyen TX, Vu TT, Nguyen BTT, Nguyen NQ, Nguyen BT, Nguyen BT, Nguyen TN, Phan SV, Nguyen AT, Pham TL, Dang HT, Kalisch-Ellett L, Gillam M, Pratt N, Qiang S, Wang H, Kanjanarach T, Hassali MAA, Babar ZUD, Razak AA, Chinwong D, Roughead EE. Use of Potentially Inappropriate Medications in People With Dementia in Vietnam and Its Associated Factors. Am J Alzheimers Dis Other Demen 2018; 33:423-432. [PMID: 29642720 PMCID: PMC10852524 DOI: 10.1177/1533317518768999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
This study examined the use of potentially inappropriate medicines that may affect cognition (PIMcog) in people with dementia and its associated factors. Medical records of all outpatients with dementia attending a tertiary hospital in Vietnam between January 1, 2015, and December 31, 2016, were examined. Medicine use was assessed against a list of PIMcog. Variables associated with having a PIMcog were assessed using a multiple logistic regression. Of the 128 patients, 41% used a PIMcog, 39.1% used cholinesterase inhibitors (CEIs) concomitantly with anticholinergics, and 18% used antipsychotics. The number of hospital visits (adjusted odds ratio [OR]: 1.08; 95% confidence interval [CI]: 1.02-1.16) and number of treating specialists (adjusted OR: 0.61; 95% CI: 0.45-0.83) were associated with PIMcog use. This study highlights a high-level use of medicines that can further impair cognition or reduce the effectiveness of CEIs in people with dementia. Efforts to improve quality use of medicines for this population are warranted.
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Affiliation(s)
- Tuan Anh Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Thang Pham
- National Geriatric Hospital of Vietnam, Hanoi, Vietnam
| | | | | | - Trinh Thi Vu
- National Geriatric Hospital of Vietnam, Hanoi, Vietnam
| | | | | | | | | | | | | | | | - Tuan Le Pham
- Hanoi Medical University and Ministry of Health of Vietnam, Hanoi, Vietnam
| | - Ha Thu Dang
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Lisa Kalisch-Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Marianne Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Sun Qiang
- Center for Health Management and Policy, School of Health Care Management, Shandong University, Jinan, China
| | - Haipeng Wang
- Center for Health Management and Policy, School of Health Care Management, Shandong University, Jinan, China
| | | | | | | | - Asrenee Ab Razak
- Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Dujrudee Chinwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
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Navaratnam V, Root AA, Douglas I, Smeeth L, Hubbard RB, Quint JK. Cardiovascular Outcomes after a Respiratory Tract Infection among Adults with Non-Cystic Fibrosis Bronchiectasis: A General Population-based Study. Ann Am Thorac Soc 2018; 15:315-321. [PMID: 29266966 PMCID: PMC5880522 DOI: 10.1513/annalsats.201706-488oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 12/20/2017] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Studies suggest that adults with bronchiectasis are at increased risk of cardiovascular comorbidities. OBJECTIVES We aimed to quantify the relative risk of incident cardiovascular events after a respiratory tract infection among adults with bronchiectasis. METHODS Using UK electronic primary care records, we conducted a within-person comparison using the self-controlled case series method. We calculated the relative risk of first-time cardiovascular events (either first myocardial infarction or stroke) after a respiratory tract infection compared with the individual's baseline risk. RESULTS Our cohort consisted of 895 adult men and women with non-cystic fibrosis bronchiectasis with a first myocardial infarction or stroke and at least one respiratory tract infection. There was an increased rate of first-time cardiovascular events in the 91-day period after a respiratory tract infection (incidence rate ratio, 1.56; 95% confidence interval, 1.20-2.02). The rate of a first cardiovascular event was highest in the first 3 days after a respiratory tract infection (incidence rate ratio, 2.73; 95% confidence interval, 1.41-5.27). CONCLUSIONS These data suggest that respiratory tract infections are strongly associated with a transient increased risk of first-time myocardial infarction or stroke among people with bronchiectasis. As respiratory tract infections are six times more common in people with bronchiectasis than the general population, the increased risk has a disproportionately greater impact in these individuals. These findings may have implications for including cardiovascular risk modifications in airway infection treatment pathways in this population.
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Affiliation(s)
- Vidya Navaratnam
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
- Department of Respiratory Epidemiology, Occupational Medicine, and Public Health, National Heart and Lung Institute, Imperial College London, United Kingdom; and
| | - Adrian A. Root
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ian Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard B. Hubbard
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Jennifer K. Quint
- Department of Respiratory Epidemiology, Occupational Medicine, and Public Health, National Heart and Lung Institute, Imperial College London, United Kingdom; and
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Arnold I, Straube K, Himmel W, Heinemann S, Weiss V, Heyden L, Hummers-Pradier E, Nau R. High prevalence of prescription of psychotropic drugs for older patients in a general hospital. BMC Pharmacol Toxicol 2017; 18:76. [PMID: 29202811 PMCID: PMC5715648 DOI: 10.1186/s40360-017-0183-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 11/23/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many elderly patients receive psychotropic drugs. Treatment with psychotropic agents is associated with serious side effects including an increased risk of falls and fractures. Several psychotropic drugs are considered potentially inappropriate for treatment of the elderly. METHODS A retrospective chart review was conducted covering all patients aged ≥ 65 years who were admitted to Evangelisches Krankenhaus Göttingen-Weende between 01/01/2013 and 03/31/2013. Psychotropic drugs reviewed for included benzodiazepines, Z-drugs, antidepressants and neuroleptics, but not drugs for sedation during artificial ventilation or pre-medication before surgery. Potentially inappropriate drugs were identified according to the PRISCUS list. To assess which factors were associated with the administration of psychotropic drugs, univariate and multivariable logistic regression analyses were performed. RESULTS The charts of 2130 patients (1231 women) were analyzed. 53.9% of all patients received at least one psychotropic medication (29.5% benzodiazepines, 12.6% Z-drugs, 22.2% antidepressants, 11.9% neuroleptics). The mean number of psychotropic drugs prescribed per patient with at least one prescription was 1.6. Patients treated in the geriatric department most often received antidepressants (45.0%), neuroleptics (20.6%) and Z-drugs (27.5%). Benzodiazepines and Z-drugs were prescribed mostly as medication on demand (77.7% of benzodiazepines, 73.9% of Z-drugs). Surgical patients most frequently received benzodiazepines (37.1%). Nearly one-third of all patients ≥ 65 years was treated with at least one potentially inappropriate psychotropic medication. The mean number of potentially inappropriate psychotropic medications per patient with at least one psychotropic prescription was 0.69. The percentage of patients with potentially inappropriate psychotropic medication was highest in the surgical departments (74.1%). Female gender (adjusted OR 1.36; 95% CI 1.14 to 1.63), stay in the Department of Geriatrics (2.69; 2.01 to 3.60) or the interdisciplinary intensive care unit (1.87; 1.33 to 2.64) and age ≥ 85 years (1.33; 1.10 to 1.60) were associated with psychotropic drug treatment. CONCLUSIONS A high percentage of patients aged ≥ 65 years received psychotropic drugs. The chance that a potentially inappropriate psychotropic drug would be administered was highest in the surgical departments. Antidepressants, neuroleptics and Z-drugs were used surprisingly often in geriatric medicine. Educational strategies could reduce the use of psychotropic drugs and the prescription of potentially inappropriate medications.
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Affiliation(s)
- Inken Arnold
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Germany.,Institute of Neuropathology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Kati Straube
- Institute of Neuropathology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Germany.,Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany.,Department of Internal Medicine, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Germany
| | - Wolfgang Himmel
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Stephanie Heinemann
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Vivien Weiss
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Laura Heyden
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Germany.,Institute of Neuropathology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Germany.,Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Eva Hummers-Pradier
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Roland Nau
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Germany. .,Institute of Neuropathology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Germany.
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8
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Lucenteforte E, Lombardi N, Vetrano DL, La Carpia D, Mitrova Z, Kirchmayer U, Corrao G, Lapi F, Mugelli A, Vannacci A. Inappropriate pharmacological treatment in older adults affected by cardiovascular disease and other chronic comorbidities: a systematic literature review to identify potentially inappropriate prescription indicators. Clin Interv Aging 2017; 12:1761-1778. [PMID: 29089750 PMCID: PMC5656349 DOI: 10.2147/cia.s137403] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Avoiding medications in which the risks outweigh the benefits in the elderly patient is a challenge for physicians, and different criteria to identify inappropriate prescription (IP) exist to aid prescribers. Definition of IP indicators in the Italian geriatric population affected by cardiovascular disease and chronic comorbidities could be extremely useful for prescribers and could offer advantages from a public health perspective. The purpose of the present study was to identify IP indicators by means of a systematic literature review coupled with consensus criteria. A systematic search of PubMed, EMBASE, and CENTRAL databases was conducted, with the search structured around four themes and combining each with the Boolean operator “and”. The first regarded “prescriptions”, the second “adverse events”, the third “cardiovascular conditions”, and the last was planned to identify studies on “older people”. Two investigators independently reviewed titles, abstracts, full texts, and selected articles addressing IP in the elderly affected by cardiovascular condition using the following inclusion criteria: studies on people aged ≥65 years; studies on patients with no restriction on age but with data on subjects aged ≥65 years; and observational effectiveness studies. The database searches produced 5,742 citations. After removing duplicates, titles and abstracts of 3,880 records were reviewed, and 374 full texts were retrieved that met inclusion criteria. Thus, 49 studies reporting 32 potential IP indicators were included in the study. IP indicators regarded mainly drug–drug interactions, cardio- and cerebrovascular risk, bleeding risk, and gastrointestinal risk; among them, only 19 included at least one study that showed significant results, triggering a potential warning for a specific drug or class of drugs in a specific context. This systematic review demonstrates that both cardiovascular and non-cardiovascular drugs increase the risk of adverse drug reactions in older adults with cardiovascular diseases.
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Affiliation(s)
- Ersilia Lucenteforte
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | | | | | | | | | - Giovanni Corrao
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | | | - Alessandro Mugelli
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
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9
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Breining A, Bonnet-Zamponi D, Zerah L, Micheneau C, Riolacci-Dhoyen N, Chan-Chee C, Deligne J, Harlin JM, Boddaert J, Verny M, Leperre-Desplanques A. Exposure to psychotropics in the French older population living with dementia: a nationwide population-based study. Int J Geriatr Psychiatry 2017; 32:750-760. [PMID: 27237864 DOI: 10.1002/gps.4517] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 02/24/2016] [Accepted: 05/05/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Little is known about the level of psychotropic chronic exposure in all patients living with dementia. The aim of the study was to quantify chronic psychotropic exposure in older adults with dementia compared with the general population of the same age. METHODS This prospective cohort study was conducted in France between 2009 and 2011. Aged at least 65 years, 10,781,812 individuals (440,215 of them with dementia) either community based or nursing home residents were included. The numbers of single or combined prescriptions, per year for antipsychotics, antidepressants, anxiolytics, or hypnotics were measured. RESULTS Of patients with dementia, 15.5% are exposed to antipsychotics compared with 2.2% of the age-matched population (relative risk [RR] = 6.44, 95% confidence interval [CI] [6.39-6.48]), 39.5% to antidepressants compared with 12.6% (RR = 4.10, 95% CI [.4.07-4.12]), and 39.6% to anxiolytics or hypnotics compared with 26.9% (RR = 1.74, 95% CI [1.72-1.75]). Among older adults with dementia, 13.8% simultaneously consumed at least three psychotropics. All class age of older patients with dementia is more exposed to all psychotropics except for long-acting benzodiazepines. During the study period, chronic anxiolytic/hypnotic and antipsychotic exposure slightly decreased in population with dementia while chronic exposure to antidepressant drugs tended to increase. CONCLUSION This nationwide, population-based, drug-used study showed for the first time that older patients with dementia are chronically overexposed not only to antipsychotics but also to psychotropics.
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Affiliation(s)
- Alice Breining
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France
| | - Dominique Bonnet-Zamponi
- OMEDIT Ile de France, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, UMR 1123 INSERM, Paris, France
| | - Lorène Zerah
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06 and CNRS, UMR 8256 B2A, Paris, France
| | | | | | | | - Jean Deligne
- Régime Social des Indépendants, Saint Denis la Plaine, France
| | - Jean-Marc Harlin
- Caisse Centrale de la Mutualité Sociale Agricole, Bagnolet, France
| | - Jacques Boddaert
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06 and CNRS, UMR 8256 B2A, Paris, France
| | - Marc Verny
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06 and CNRS, UMR 8256 B2A, Paris, France
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10
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Brett J, Elshaug AG, Bhatia RS, Chalmers K, Badgery-Parker T, Pearson SA. A methodological protocol for selecting and quantifying low-value prescribing practices in routinely collected data: an Australian case study. Implement Sci 2017; 12:58. [PMID: 28468629 PMCID: PMC5415810 DOI: 10.1186/s13012-017-0585-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 04/18/2017] [Indexed: 12/04/2022] Open
Abstract
Background Growing imperatives for safety, quality and responsible resource allocation have prompted renewed efforts to identify and quantify harmful or wasteful (low-value) medical practices such as test ordering, procedures and prescribing. Quantifying these practices at a population level using routinely collected health data allows us to understand the scale of low-value medical practices, measure practice change following specific interventions and prioritise policy decisions. To date, almost all research examining health care through the low-value lens has focused on medical services (tests and procedures) rather than on prescribing. The protocol described herein outlines a program of research funded by Australia’s National Health and Medical Research Council to select and quantify low-value prescribing practices within Australian routinely collected health data. Methods We start by describing our process for identifying and cataloguing international low-value prescribing practices. We then outline our approach to translate these prescribing practices into indicators that can be applied to Australian routinely collected health data. Next, we detail methods of using Australian health data to quantify these prescribing practices (e.g. prevalence of low-value prescribing and related costs) and their downstream health consequences. We have approval from the necessary Australian state and commonwealth human research ethics and data access committees to undertake this work. Discussion The lack of systematic and transparent approaches to quantification of low-value practices in routinely collected data has been noted in recent reviews. Here, we present a methodology applied in the Australian context with the aim of demonstrating principles that can be applied across jurisdictions in order to harmonise international efforts to measure low-value prescribing. The outcomes of this research will be submitted to international peer-reviewed journals. Results will also be presented at national and international pharmacoepidemiology and health policy forums such that other jurisdictions have guidance to adapt this methodology. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0585-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonathan Brett
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Level 1, AGSM Building (G27), Sydney, NSW, 2052, Australia
| | - Adam G Elshaug
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Level 6 The Hub, Charles Perkins Centre D17, Sydney, NSW, 2006, Australia
| | - R Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Canada
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Level 6 The Hub, Charles Perkins Centre D17, Sydney, NSW, 2006, Australia
| | - Tim Badgery-Parker
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Level 6 The Hub, Charles Perkins Centre D17, Sydney, NSW, 2006, Australia
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Level 1, AGSM Building (G27), Sydney, NSW, 2052, Australia. .,Menzies Centre for Health Policy, School of Public Health, University of Sydney, Level 6 The Hub, Charles Perkins Centre D17, Sydney, NSW, 2006, Australia.
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11
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Hsu WT, Esmaily-Fard A, Lai CC, Zala D, Lee SH, Chang SS, Lee CC. Antipsychotics and the Risk of Cerebrovascular Accident: A Systematic Review and Meta-Analysis of Observational Studies. J Am Med Dir Assoc 2017; 18:692-699. [PMID: 28431909 DOI: 10.1016/j.jamda.2017.02.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 02/24/2017] [Accepted: 02/28/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Studies investigating the association between antipsychotic use and the risk of cerebrovascular accident (CVA) showed inconsistent results. AIM Conduct a systematic review and meta-analysis to evaluate whether use of antipsychotics is associated with increased risk of CVA. METHODS Major electronic databases were searched from 1970 to October 2016 for observational studies investigating the risk of CVA among users of antipsychotics. Pooled estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were obtained by random effects meta-analysis. RESULTS Of 1171 citations identified, 10 studies were considered eligible. Significant increase in risk of CVA was associated with first-generation antipsychotics (OR 1.49; 95% CI 1.24-1.77) but not with second-generation antipsychotics (OR 1.31; 95% CI 0.74-2.30). Use of any antipsychotics in patients with dementia was associated with a low risk of CVA (OR 1.17; 95% CI 1.08-1.26). CONCLUSIONS The available evidence suggests use of with first-generation antipsychotics as opposed to second-generation antipsychotics significantly increased the risk of CVA.
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Affiliation(s)
- Wan-Ting Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Health Economics and Outcome Research Group, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Darshan Zala
- Institute of Psychiatry, Psychology and Neuroscience at King's College London, London, United Kingdom
| | - Sie-Huei Lee
- Institute of Psychiatry, Psychology and Neuroscience at King's College London, London, United Kingdom; Department of Medicine, College of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Shy-Shin Chang
- Department of Family Medicine, Chang-Gung University Hospital, Linkou, Taiwan; Graduate Institute of Clinical Medicine, Chang-Gung University Hospital, Linkou, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Health Economics and Outcome Research Group, National Taiwan University Hospital, Taipei, Taiwan.
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12
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Takeuchi Y, Ando T, Ishiguro C, Uyama Y. Risk of Acute Asthma Attacks Associated With Nonsteroidal Anti-inflammatory Drugs: A Self-Controlled Case Series. Ther Innov Regul Sci 2016; 51:332-341. [PMID: 30231709 DOI: 10.1177/2168479016679865] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although asthma attacks are known adverse events associated with nonsteroidal anti-inflammatory drug (NSAID) use, few studies have quantified these risks. The objectives of this study were to utilize an epidemiological approach to quantitatively evaluate the risk of acute asthma attacks associated with NSAID prescription in Japan and to compare the risks among NSAIDs according to their cyclooxygenase (COX)-2 selectivity. METHODS We conducted a self-controlled case series study using Japanese health insurance claims data. Exposed cases were identified as those who had experienced both NSAID prescription and acute asthma attack, which was defined as the combination of an inhalation procedure and the prescription of any inhaled β2-agonist. The incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for NSAID prescription periods compared with baseline periods were calculated using conditional Poisson regression models; COX-2 selective and nonselective NSAIDs were similarly compared. RESULTS We identified 9769 subjects, more than 95% of whom were younger than 60 years. There was a significantly higher risk of acute asthma attacks during the NSAID prescription period when compared with the baseline period. The quantified IRRs were, in descending order, 93.94 (95% CI, 90.10-97.95) for the prescription start date, 3.96 (95% CI, 3.63-4.33) for 1 to 9 days after the prescription start date, 3.01 (95% CI, 2.78-3.25) for 7 days after the prescription end date, 2.19 (95% CI, 1.82-2.65) for >9 days after the prescription start date, and 1.44 (95% CI, 1.29 -1.61) for 7 days before the prescription start date. There were lower asthmatic risks for COX-2 selective NSAIDs compared with nonselective NSAIDs. CONCLUSIONS The use of NSAIDs in Japan was associated with an increased risk of acute asthma attacks. However, this risk was lower in COX-2 selective NSAIDs.
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Affiliation(s)
- Yoshinori Takeuchi
- 1 Office of Medical Informatics and Epidemiology, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Takashi Ando
- 1 Office of Medical Informatics and Epidemiology, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Chieko Ishiguro
- 1 Office of Medical Informatics and Epidemiology, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Yoshiaki Uyama
- 1 Office of Medical Informatics and Epidemiology, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
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13
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The use of antipsychotics among people treated with medications for dementia in residential aged care facilities. Int Psychogeriatr 2016; 28:977-82. [PMID: 26775538 DOI: 10.1017/s1041610215002434] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Antipsychotic agents have limited efficacy for Behavioral and Psychological Symptoms of Dementia (BPSD) and there are concerns about their safety. Despite this, they are frequently used for the management of BPSD. This study aimed to assess the use of antipsychotics among people on anti-dementia medicines in Australian residential aged care facilities. METHODS Data were obtained from an individual patient unit dose packaging database covering 40 residential aged care facilities in New South Wales, Australia. Residents supplied an anti-dementia medicine between July 2008 and June 2013 were included. Prevalence of concurrent antipsychotic use was established. Incident antipsychotic users between January 2009 and December 2011 were identified. We examined initial antipsychotic dose, maximum titrated doses, type and duration of antipsychotic use, and compared use with Australian guidelines. RESULTS There were 291 residents treated with anti-dementia medicines, 129 (44%) of whom received antipsychotics concomitantly with an anti-dementia medicine. Among the 59 incident antipsychotic users, risperidone (73%) was the most commonly used antipsychotic agent. Amongst the risperidone initiators, 43% of patients had initial doses greater than 0.5 mg/day and 6% of patients exceeded 2.0 mg/day for their maximum dose. 53% of concomitant users received daily treatment for greater than six months. CONCLUSIONS Our study using records of individual patient unit dose supply, which represents the intended medication consumption schedule, shows high rates of concurrent use of antipsychotics and anti-dementia medicines and long durations of use. The use of antipsychotics in patients with dementia needs to be carefully monitored to improve patient outcomes.
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Abstract
Observational studies have been recognised to be essential for investigating the safety profile of medications. Numerous observational studies have been conducted on the platform of large population databases, which provide adequate sample size and follow-up length to detect infrequent and/or delayed clinical outcomes. Cohort and case-control are well-accepted traditional methodologies for hypothesis testing, while within-individual study designs are developing and evolving, addressing previous known methodological limitations to reduce confounding and bias. Respective examples of observational studies of different study designs using medical databases are shown. Methodology characteristics, study assumptions, strengths and weaknesses of each method are discussed in this review.
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15
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Jennum P, Baandrup L, Iversen HK, Ibsen R, Kjellberg J. Mortality and use of psychotropic medication in patients with stroke: a population-wide, register-based study. BMJ Open 2016; 6:e010662. [PMID: 26956165 PMCID: PMC4785303 DOI: 10.1136/bmjopen-2015-010662] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES The study sought to describe whether psychotropic medication may have long-term side effects in patients with stroke compared with controls. SETTING Use of national register data from healthcare services were identified from the Danish National Patient Registry in Denmark. Information about psychotropic medication use was obtained from the Danish Register of Medicinal Product Statistics. OBJECTIVES We aimed to evaluate all-cause mortality in relation to the use of benzodiazepines, antidepressants and antipsychotics in patients with stroke and matched controls. PARTICIPANTS Patients with a diagnosis of stroke and either no drug use or preindex use of psychotropic medication (n=49,968) and compared with control subjects (n=86,100) matched on age, gender, marital status and community location. PRIMARY OUTCOME MEASURE All-cause mortality. RESULTS All-cause mortality was higher in patients with previous stroke compared with control subjects. Mortality HRs were increased for participants prescribed serotonergic antidepressant drugs (HR=1.699 (SD=0.030), p=0.001 in patients; HR=1.908 (0.022), p<0.001 in controls, respectively), tricyclic antidepressants (HR=1.365 (0.045), p<0.001; HR=1.733 (0.022), p<0.001), benzodiazepines (HR=1.643 (0.040), p<0.001; HR=1.776 (0.053), p<0.001), benzodiazepine-like drugs (HR=1.776 (0.021), p<0.001; HR=1.547 (0.025), p<0.001), first-generation antipsychotics (HR=2.001 (0.076), p<0.001; HR=3.361 (0.159), p<0.001) and second-generation antipsychotics (HR=1.645 (0.070), p<0.001; HR=2.555 (0.086), p<0.001), compared with no drug use. Interaction analysis suggested statistically significantly higher mortality HRs for most classes of psychotropic drugs in controls compared with patients with stroke. CONCLUSIONS All-cause mortality was higher in patients with stroke and controls treated with benzodiazepines, antidepressants and antipsychotics than in their untreated counterparts. Our findings suggest that care should be taken in the use and prescription of such drugs, and that they should be used in conjunction with adequate clinical controls.
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Affiliation(s)
- Poul Jennum
- Faculty of Health Sciences, Danish Center for Sleep Medicine, Neurophysiology Clinic, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Lone Baandrup
- Center for Neuropsychiatric Schizophrenia Research & Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research, Mental Health Center Glostrup, Copenhagen University Hospital, Glostrup, Denmark
| | - Helle K Iversen
- Stroke Unit, Department of Neurology, Faculty of Health Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | | | - Jakob Kjellberg
- Danish National Institute for Local and Regional Government Research, Copenhagen, Denmark
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16
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Correll CU, Joffe BI, Rosen LM, Sullivan TB, Joffe RT. Cardiovascular and cerebrovascular risk factors and events associated with second-generation antipsychotic compared to antidepressant use in a non-elderly adult sample: results from a claims-based inception cohort study. World Psychiatry 2015; 14:56-63. [PMID: 25655159 PMCID: PMC4329898 DOI: 10.1002/wps.20187] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
This is a study of the metabolic and distal cardiovascular/cerebrovascular outcomes associated with the use of second-generation antipsychotics (SGAs) compared to antidepressants (ADs) in adults aged 18-65 years, based on data from Thomson Reuters MarketScan® Research Databases 2006-2010, a commercial U.S. claims database. Interventions included clinicians' choice treatment with SGAs (allowing any comedications) versus ADs (not allowing SGAs). The primary outcomes of interest were time to inpatient or outpatient claims for the following diagnoses within one year of SGA or AD discontinuation: hypertension, ischemic and hypertensive heart disease, cerebrovascular disease, diabetes mellitus, hyperlipidemia, and obesity. Secondary outcomes included the same diagnoses at last follow-up time point, i.e., not censoring observations at 365 days after SGA or AD discontinuation. Cox regression models, adjusted for age, gender, diagnosis of schizophrenia and mood disorders, and number of medical comorbidities, were run. Among 284,234 individuals, those within one year of exposure to SGAs versus ADs showed a higher risk of essential hypertension (adjusted hazard ratio, AHR=1.16, 95% CI: 1.12-1.21, p<0.0001), diabetes mellitus (AHR=1.43, CI: 1.33-1.53, p<0.0001), hypertensive heart disease (AHR=1.34, CI: 1.10-1.63, p<0.01), stroke (AHR=1.46, CI: 1.22-1.75, p<0.0001), coronary artery disease (AHR=1.17, CI: 1.05-1.30, p<0.01), and hyperlipidemia (AHR=1.12, CI: 1.07-1.17, p<0.0001). Unrestricted follow-up results were consistent with within one-year post-exposure results. Increased risk for stroke with SGAs has previously only been demonstrated in elderly patients, usually with dementia. This study documents, for the first time, a significantly increased risk for stroke and coronary artery disease in a non-elderly adult sample with SGA use. We also confirm a significant risk for adverse metabolic outcomes. These findings raise concerns about the longer-term safety of SGAs, given their widespread and chronic use.
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Affiliation(s)
- Christoph U Correll
- Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health SystemGlen Oaks, New York, NY, USA,Hofstra North Shore - Long Island Jewish School of MedicineHempstead, New York, NY, USA,Feinstein Institute for Medical ResearchManhasset, New York, NY, USA,Long Island Jewish - North Shore Staten Island University HospitalStaten Island, New York, NY, USA
| | | | - Lisa M Rosen
- Feinstein Institute for Medical ResearchManhasset, New York, NY, USA
| | - Timothy B Sullivan
- Long Island Jewish - North Shore Staten Island University HospitalStaten Island, New York, NY, USA,New York Medical CollegeValhalla, NY, USA
| | - Russell T Joffe
- Hofstra North Shore - Long Island Jewish School of MedicineHempstead, New York, NY, USA,Long Island Jewish - North Shore Staten Island University HospitalStaten Island, New York, NY, USA,Boston University School of MedicineBoston, MA, USA
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17
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18
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Kalisch Ellett LM, Pratt NL, Barratt JD, Rowett D, Roughead EE. Risk of Medication-Associated Initiation of Oxybutynin in Elderly Men and Women. J Am Geriatr Soc 2014; 62:690-5. [DOI: 10.1111/jgs.12741] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia Australia
| | - Nicole L. Pratt
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia Australia
| | - John D. Barratt
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia Australia
| | - Debra Rowett
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia Australia
- Drug and Therapeutics Information Service; Repatriation General Hospital; Adelaide South Australia Australia
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research Centre; School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia Australia
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19
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Cocchi E, Drago A, de Ronchi D, Serretti A. The genetics of vascular incidents associated with second-generation antipsychotic administration. Expert Rev Clin Pharmacol 2013; 7:75-90. [PMID: 24325740 DOI: 10.1586/17512433.2014.865515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Second-generation antipsychotics (SGA) have been associated with risk of stroke in elderly patients, but the molecular and genetic background under this association has been poorly investigated. The aim of the present study was to prioritize a list of genes with an SGA altered expression in order to characterize the genetic background of the SGA-associated stroke risk. Genes with evidence of an altered expression after SGA treatments in genome-wide investigations, both in animals and men, were identified. The Genetic Association Database (GAD) served to verify which of these genes had a proven positive association with an increased stroke risk, and along with it each evidence was tested and recorded. Seven hundred and forty five genes had evidence of a change of their expression profile after SGA administration in various studies. Nine out of them have also been significantly related to an increased strokes risk. We identified and described nine genes as potential candidates for future genetic studies aimed at identifying the genetic background of the SGA-related stroke risk. Further, we identify the molecular pathways in which these genes operate in order to provide a molecular framework to understand on which basis SGA may enhance the risk for stroke.
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Affiliation(s)
- Enrico Cocchi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Italy
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20
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Roughead EE, Kalisch Ellett LM, Ramsay EN, Pratt NL, Barratt JD, LeBlanc VT, Ryan P, Peck R, Killer G, Gilbert AL. Bridging evidence-practice gaps: improving use of medicines in elderly Australian veterans. BMC Health Serv Res 2013; 13:514. [PMID: 24330781 PMCID: PMC3878826 DOI: 10.1186/1472-6963-13-514] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 12/10/2013] [Indexed: 11/29/2022] Open
Abstract
Background The Australian Government Department of Veterans’ Affairs (DVA) funds an ongoing health promotion based program to improve use of medicines and related health services, which implements interventions that include audit and feedback in the form of patient-specific feedback generated from administrative claims records. We aimed to determine changes in medicine use as a result of the program. Methods The program provides targeted patient-specific feedback to medical practitioners. The feedback is supported with educational material developed by a clinical panel, subject to peer review and overseen by a national editorial committee. Veterans who meet target criteria also receive educational brochures. The program is supported by a national call centre and ongoing national consultation. Segmented regression analyses (interrupted time series) were undertaken to assess changes in medication use in targeted veterans pre and post each intervention. Results 12 interventions were included; three to increase medicine use, seven which aimed to reduce use, and two which had combination of messages to change use. All programs that aimed to increase medicine use were effective, with relative effect sizes at the time of the intervention ranging from 1% to 8%. Mixed results were seen with programs aiming to reduce inappropriate medicine use. Highly specific programs were effective, with relative effect sizes at the time of the intervention of 10% decline in use of NSAIDs in high risk groups and 14% decline in use of antipsychotics in dementia. Interventions targeting combinations of medicines, including medicine interactions and potentially inappropriate medicines in the elderly did not change practice significantly. Interventions with combinations of messages targeting multiple components of practice had an impact on one component, but not all components targeted. Conclusions The Veterans’ MATES program showed positive practice change over time, with interventions increasing use of appropriate medicines where under-use was evident and reduced use of inappropriate medicines when single medicines were targeted. Combinations of messages were less effective, suggesting specific messages focusing on single medicines are required to maximise effect. The program provides a model that could be replicated in other settings.
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Affiliation(s)
| | - Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, Australia.
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Abstract
The aim of this study was to investigate the association between the use of antipsychotics and the risk of venous thromboembolism (VTE) in elderly patients with dementia. Based on data from the German Pharmacoepidemiological Research Database, a nested case-control study was conducted within a cohort of 72,591 patients with dementia aged at least 65 years at cohort entry. Cases were patients with a hospitalization due to VTE. Up to 4 controls were matched to each case according to age, sex, health insurance, and calendar time of the VTE. Users of antipsychotics were classified into current or former users, and in addition, all current users were categorized as prevalent or new users. For a further analysis, we distinguished between users of either conventional or atypical antipsychotics or concurrent users of both conventional and atypical antipsychotics. Multivariate conditional logistic regression was applied to calculate odds ratios (ORs) of VTE for all user groups compared with nonusers. The case-control data set comprised 1028 VTE cases and 4109 controls. An increased risk of VTE was found for current users (OR, 1.23; 95% confidence interval [CI], 1.01-1.50) and for users of a combination of atypical and conventional antipsychotics (OR, 1.62; 95% CI, 1.15-2.27). In current users, only new use was associated with an increased risk (OR, 1.63; 95% CI, 1.10-2.40). Increased attention to clinical signs of VTE should be paid during the first 3 months of treatment with antipsychotics and in patients receiving both conventional and atypical agents, especially if other risk factors for VTE exist.
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22
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Mohammed SM, Dalrymple LS, Şentürk D, Nguyen DV. Naive hypothesis testing for case series analysis with time-varying exposure onset measurement error: inference for infection-cardiovascular risk in patients on dialysis. Biometrics 2013; 69:520-9. [PMID: 23731166 DOI: 10.1111/biom.12033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 12/01/2012] [Accepted: 01/01/2013] [Indexed: 11/26/2022]
Abstract
The case series method is useful in studying the relationship between time-varying exposures, such as infections, and acute events observed during the observation periods of individuals. It provides estimates of the relative incidences of events in risk periods (e.g., 30-day period after infections) relative to the baseline periods. When the times of exposure onsets are not known precisely, application of the case series model ignoring exposure onset measurement error leads to biased estimates. Bias-correction is necessary in order to understand the true directions and effect sizes associated with exposure risk periods, although uncorrected estimators have smaller variance. Thus, inference via hypothesis testing based on uncorrected test statistics, if valid, is potentially more powerful. Furthermore, the tests can be implemented in standard software and do not require additional auxiliary data. In this work, we examine the validity and power of naive hypothesis testing, based on applying the case series analysis to the imprecise data without correcting for the error. Based on simulation studies and theoretical calculations, we determine the validity and relative power of common hypothesis tests of interest in case series analysis. In particular, we illustrate that the tests for the global null hypothesis, the overall null hypotheses associated with all risk periods or all age effects are valid. However, tests of individual risk period parameters are not generally valid. Practical guidelines are provided and illustrated with data from patients on dialysis.
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Affiliation(s)
- Sandra M Mohammed
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, CA 95616, USA
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23
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Douglas IJ, Langham J, Bhaskaran K, Brauer R, Smeeth L. Orlistat and the risk of acute liver injury: self controlled case series study in UK Clinical Practice Research Datalink. BMJ 2013; 346:f1936. [PMID: 23585064 PMCID: PMC3624963 DOI: 10.1136/bmj.f1936] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To measure the association between orlistat and acute liver injury. DESIGN Self controlled case series study. SETTING Population based primary care setting, United Kingdom. PARTICIPANTS 94,695 patients receiving orlistat and registered in the UK Clinical Practice Research Datalink and linked with Hospital Episode Statistics data between 1999 and 2011. MAIN OUTCOME MEASURE Relative incidence of acute liver injury comparing periods when patients were receiving orlistat with periods of non-usage. RESULTS Among 94,695 patients who received orlistat, 988 cases of acute liver injury were identified, with 335 confirmed as definite cases and 653 as probable cases. For all cases an increased incidence of liver injury was detected during the 90 day period before orlistat was first started, with an incidence rate ratio of 1.50 (95% confidence interval 1.10 to 2.06). The incidence remained raised during the first 30 days of treatment (2.21, 1.43 to 3.42), before returning to baseline levels with prolonged treatment. When the risk during the first 90 days of treatment was compared with the 90 days preceding first treatment, the incidence of liver injury was not increased (1.02, 0.67 to 1.56). An analysis restricted to definite cases showed no evidence of an increased risk of liver injury during treatment. CONCLUSION The incidence of acute liver injury was higher in the periods both immediately before and immediately after the start of orlistat treatment. This suggests that the observed increased risks of liver injury linked to the start of treatment may reflect changes in health status associated with the decision to begin treatment rather than any causal effect of the drug.
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Affiliation(s)
- Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
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Antipsychotics in nursing homes. J Clin Psychopharmacol 2013; 33:1-2. [PMID: 23277258 DOI: 10.1097/jcp.0b013e31827cad8c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Song SW, Sun Y, Su BL, Liu C, Yang C, Godfraind T, Su DF. Risperidone enhances the vulnerability to stroke in hypertensive rats. CNS Neurosci Ther 2013; 18:343-9. [PMID: 22486847 DOI: 10.1111/j.1755-5949.2012.00302.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Stroke is the second most common cause of death and a major cause of disability worldwide. Risperidone is an atypical antipsychotic drug that may increase the risk of stroke. The present work examined whether risperidone enhances the vulnerability to stroke in hypertensive rats and the potential mechanisms underlying such action. METHODS Experiment 1: Wistar-Kyoto (WKY) rats, spontaneously hypertensive rats (SHRs) and stroke-prone SHRs (SHR-SPs) were treated with risperidone (0.8 and 2.4 mg/kg/d) or vehicle for 30 consecutive days. Tissue damage in response to middle cerebral artery occlusion (MCAO) was measured microscopically. The activity of superoxide dismutase, glutathione peroxidase, the levels of malondialdehyde were also determined. Experiment 2: Survival data were recorded in SHR-SPs that received daily risperidone perpetually. Experiment 3: Effect of risperidone on interleukin-6 and tumor necrosis factor-α was examined in quiescent or LPS-activated cortical microglias from WKY rats. Experiment 4: Potential damage of risperidone exposure to neurons was examined in primary neuronal culture obtained from WKY rats, SHRs, and SHR-SPs. RESULTS Risperidone increased infarct areas upon MCAO in SHR-SPs and SHRs, but not in WKY rats. Survival time in SHR-SPs was shortened by risperidone. Apoptosis was augmented by risperidone through enhanced Bax. Risperidone also increased endothelial injury. CONCLUSIONS Risperidone enhances the vulnerability to stroke in hypertensive rats through increasing neuronal apoptosis and endothelial injury.
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Affiliation(s)
- Shu-Wei Song
- Department of Pharmacology, School of Pharmacy, Second Military Medical University, Shanghai, China
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Abstract
Older people reaching end-of-life status are particularly at risk of adverse effects of drug therapy. Polypharmacy, declining organ function, co-morbidity, malnutrition, cachexia and changes in body composition all sum up to increase the risk of many drug-related problems in individuals who receive end-of-life care. End of life is defined by a limited lifespan or advanced disability. Optimal prescribing for end-of-life patients with multimorbidity, especially in those dying from non-cancer conditions, remains mostly unexplored, despite the increasing recognition that the management goals for patients with chronic diseases should be redefined in the setting of reduced life expectancy. Most drugs used for symptom palliation in end-of-life care of older patients are used without solid evidence of their benefits and risks in this particularly frail population. Appropriate dosing or optimal administration routes are in most cases unknown. Avoiding or discontinuing drugs that aim to prolong life or prevent disability is usually common sense in end-of-life care, particularly when the time needed to obtain the expected benefits from the drug is longer than the life expectancy of a particular individual. However, discontinuation of drugs is not standard practice, and prescriptions are usually not adapted to changes in the course of advanced diseases. Careful consideration of remaining life expectancy, time until benefit, goals of care and treatment targets for each drug seems to be a sensible framework for decision making. In this article, some key issues on drug therapy at the end of life are discussed, including principles of decision making about drug treatments, specific aspects of drug therapy in some common geriatric conditions (heart failure and dementia), treatment of acute concurrent problems such as infections, evidence to guide the choice and use of drugs to treat symptoms in palliative care, and avoidance of some long-term therapies in end-of-life care. Solid evidence is lacking to guide optimal pharmacotherapy in most end-of-life settings, especially in non-cancer diseases and very old patients. Some open questions for research are suggested.
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Douglas IJ, Evans SJW, Hingorani AD, Grosso AM, Timmis A, Hemingway H, Smeeth L. Clopidogrel and interaction with proton pump inhibitors: comparison between cohort and within person study designs. BMJ 2012; 345:e4388. [PMID: 22782731 PMCID: PMC3392956 DOI: 10.1136/bmj.e4388] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To measure the association between use of proton pump inhibitors and a range of harmful outcomes in patients using clopidogrel and aspirin. DESIGN Observational cohort study and self controlled case series. SETTING United Kingdom General Practice Research Database with linked data from the Myocardial Ischaemia National Audit Project (MINAP) and the Office for National Statistics (the cardiovascular disease research using linked bespoke studies and electronic records (CALIBER) collaboration) POPULATION 24,471 patients receiving clopidogrel and aspirin. MAIN OUTCOME MEASURES The primary outcome was death or incident myocardial infarction. Secondary outcomes were death, incident myocardial infarction, vascular death, and non-vascular death. Comparisons were made between proton pump inhibitor use and non-use. RESULTS Of the 24,471 patients prescribed clopidogrel and aspirin, 12,439 (50%) were also prescribed a proton pump inhibitor at some time during the study. Death or incident myocardial infarction occurred in 1419 (11%) patients while they were receiving a proton pump inhibitor compared with 1341 (8%) who were not receiving a proton pump inhibitor. In multivariate analysis, the hazard ratio for the association between proton pump inhibitor use and death or incident myocardial infarction was 1.37 (95% confidence interval 1.27 to 1.48). Comparable results were seen for secondary outcomes and with other 2C19 inhibitors and with non-2C19 inhibitors. With the self controlled case series design to remove the effect of differences between people, there was no association between proton pump inhibitor use and myocardial infarction, with a rate ratio of 0.75 (0.55 to 1.01). Similarly, with the self controlled case series there was no association with myocardial infarction for other 2C19 inhibitors/non-inhibitors. CONCLUSION The lack of a specific association and the discrepancy between findings of the analyses between and within people suggests that the interaction between proton pump inhibitors and clopidogrel is clinically unimportant.
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Affiliation(s)
- Ian J Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
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Pratt N, Roughead EE, Salter A, Ryan P. Choice of observational study design impacts on measurement of antipsychotic risks in the elderly: a systematic review. BMC Med Res Methodol 2012; 12:72. [PMID: 22682666 PMCID: PMC3447663 DOI: 10.1186/1471-2288-12-72] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 04/18/2012] [Indexed: 12/31/2022] Open
Abstract
Background Antipsychotics are frequently and increasingly prescribed to treat the behavioural symptoms associated with dementia despite their modest efficacy. Evidence regarding the potential adverse events of antipsychotics is limited and little is known about the longer-term safety of these medicines in the elderly. The aim of this review was to determine the impact of the choice of observational study design and methods used to control for confounding on the measurement of antipsychotic risks in elderly patients. Methods We searched PUBMED and the Cochrane controlled trials register for double-blind randomised controlled trials (RCTs), meta-analyses and published observational studies of antipsychotics. Results Forty four studies were identified for the endpoints; death, cerebrovascular events, hip fracture and pneumonia. RCTs found a 20% to 30% increased risk of death, or an absolute increase of 1extra death per 100 patients with atypical antipsychotics compared to non-use. Cohort and instrumental variable analyses estimated between 2 to 7 extra deaths per 100 patients with conventional compared to atypical antipsychotics. RCTs found a 2 to 3 times increased risk of all cerebrovascular events with atypical antipsychotics compared to placebo and no association with serious stroke that required hospitalisation. Observational studies using cohort and self-controlled case-series designs reported similar results; no association where the endpoint was stroke causing hospitalisation and a doubling of risk when minor stroke was included. No RCTs were available for the outcome of hip fracture or pneumonia. Observational studies reported a 20% to 40% increased risk of hip fracture with both antipsychotic classes compared to non-use. The risk of pneumonia was a 2 to 3 times greater with both classes compared to non-use while a self-controlled case-series study estimated a 60% increased risk. Conventional antipsychotics were associated with a 50% greater hip fracture risk than atypical antipsychotics, while the risk of pneumonia was similar between the classes. Conclusions Choice of observational study design is critical in studying the adverse effects of antispychotics. Cohort and instrumental variable analyses gave more consistent results to clinical studies for mortality outcomes as have self-controlled case-series for the risk of cerebrovascular events and stroke. Observational evidence has highlighted the potential for antipsychotics to be associated with serious adverse events that were not reported in RCTs including hip fracture and pneumonia. Good quality observational studies are required, that employ appropriate study designs that are robust towards unmeasured confounding, to confirm the potential excess risk of hip fracture and pneumonia with antipsychotics.
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Affiliation(s)
- Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute, University of South Australia, Adelaide, Australia.
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Ramsay EN, Roughead EE, Ewald B, Pratt NL, Ryan P. A self-controlled case series to assess the effectiveness of beta blockers for heart failure in reducing hospitalisations in the elderly. BMC Med Res Methodol 2011; 11:106. [PMID: 21762536 PMCID: PMC3161026 DOI: 10.1186/1471-2288-11-106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 07/18/2011] [Indexed: 11/10/2022] Open
Abstract
Background To determine the suitability of using the self-controlled case series design to assess improvements in health outcomes using the effectiveness of beta blockers for heart failure in reducing hospitalisations as the example. Methods The Australian Government Department of Veterans' Affairs administrative claims database was used to undertake a self-controlled case-series in elderly patients aged 65 years or over to compare the risk of a heart failure hospitalisation during periods of being exposed and unexposed to a beta blocker. Two studies, the first using a one year period and the second using a four year period were undertaken to determine if the estimates varied due to changes in severity of heart failure over time. Results In the one year period, 3,450 patients and in the four year period, 12, 682 patients had at least one hospitalisation for heart failure. The one year period showed a non-significant decrease in hospitalisations for heart failure 4-8 months after starting beta-blockers, (RR, 0.76; 95% CI (0.57-1.02)) and a significant decrease in the 8-12 months post-initiation of a beta blocker for heart failure (RR, 0.62; 95% CI (0.39, 0.99)). For the four year study there was an increased risk of hospitalisation less than eight months post-initiation and significant but smaller decrease in the 8-12 month window (RR, 0.90; 95% CI (0.82, 0.98)). Conclusions The results of the one year observation period are similar to those observed in randomised clinical trials indicating that the self-controlled case-series method can be successfully applied to assess health outcomes. However, the result appears sensitive to the study periods used and further research to understand the appropriate applications of this method in pharmacoepidemiology is still required. The results also illustrate the benefits of extending beta blocker utilisation to the older age group of heart failure patients in which their use is common but the evidence is sparse.
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Affiliation(s)
- Emmae N Ramsay
- Data Management and Analysis Centre, Discipline of Public Health, University of Adelaide, South Australia, 5000, Australia.
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Pratt N, Roughead EE, Ramsay E, Salter A, Ryan P. Risk of Hospitalization for Hip Fracture and Pneumonia Associated with Antipsychotic Prescribing in the Elderly. Drug Saf 2011; 34:567-75. [PMID: 21663332 DOI: 10.2165/11588470-000000000-00000] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Nicole Pratt
- Data Management and Analysis Centre, Discipline of Public Health, University of Adelaide, Australia.
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