Medicines Regimens Charted for Older People Living in Residential Aged Care: A Repeated Cross-Sectional Study Describing the Number of Medicines, Regimen Complexity, High-Risk Prescribing, and Potential Underprescribing

OBJECTIVE

We aimed to explore medicines regimens charted for older people living in residential aged care facilities (RACFs).

DESIGN

Repeated cross-sectional study using routinely collected data sampled in a cross-sectional manner at 11 time points (day of admission, then at 1, 3, 7, 14, and 30 days, and 3, 6, 12, 18, and 24 months post admission).

SETTING AND PARTICIPANTS

The cohort is set in 34 RACFs managed by a single Australasian provider. People aged ≥65 years admitted to permanent care between January 1, 2017, and October 1, 2021, with medicines charted on the date of admission.

METHODS

Medicines charted were evaluated for potentially suboptimal prescribing including number of medicines, high-risk prescribing (eg, potentially inappropriate medicines, anticholinergic burden), and potential underprescribing.

RESULTS

The 3802 residents in the final cohort had a mean age of 84.9 ± 7.2 years at admission. At least 1 example of suboptimal prescribing was identified in 3479 (92%) residents at admission increasing to 1410 (97%) at 24 months. The number of medicines charted for each resident increased over time from 6.0 ± 3.8 regular and 2.8 ± 2.7 as required medicines at admission to 8.9 ± 4.1 regular and 8.1 ± 3.7 as required medicines at 24 months. Anticholinergic drug burden increased from 1.6 ± 2.4 at admission to 3.0 ± 2.8 at 24 months. Half the residents (2173; 57%) used at least 1 potentially inappropriate medicine at admission, which rose to nearly three-quarters (1060; 73%) at 24 months admission.

CONCLUSION AND IMPLICATIONS

The total number of medicines charted for older adults living in RACFs increases with length of stay, with charted as required medicines nearly tripling. Effective interventions to optimize medicines use in this vulnerable population are required.

Analysis of the key themes in the healthcare of older people with multimorbidity in Germany: a framework analysis as part of the LoChro trial

OBJECTIVES

Multimorbidity challenges healthcare systems. In Germany, coordination of healthcare for older multimorbid patients remains unstructured.This study aims to identify key themes in the healthcare of these patients and the inter-relationships between them.

DESIGN

Framework analysis of six cases based on 1-year data of primary and secondary care, patient-answered questionnaires and video material.

SETTING

Southern Germany.

PARTICIPANTS

Six multimorbid older patients participating in a randomised controlled trial that compared usual care with a local, collaborative, stepped and personalised care management approach for older people with chronic diseases (LoChro-trial). The LoChro care intervention involved a care manager who assisted participants in self-management. The primary outcome was a composite of functional health and depressive symptoms at 12 and 18 months. The LoChro-intervention had no effect on the primary outcome.

PRIMARY OUTCOME MEASURE

Key themes in the healthcare of older patients with multimorbidity and the inter-relationships between them.

METHODS

One-year data included diagnoses, treatment plans, examinations, assessments and discharge reports. Patient perspectives were assessed using the Patient Assessment of Chronic Illness Care. In three cases, videos of the LoChro intervention showed patients describing their health needs. These data were evaluated by three doctors and public health researchers. Using framework analysis, recurring themes influencing the healthcare situation of multimorbid older patients and their inter-relationships were identified.

RESULTS

Participants had an average age of 77, with 13 diagnoses, taking eight medications regularly. The five key themes describing the healthcare situation of these multimorbid patients were as follows: insufficient coordination, overuse and underuse of medical care, doctor and patient roles. Each theme covered three to four subcategories. The most significant inter-relationships between these themes were a lack of coordination leading to overuse and underuse of medical care. These were characterised by redundant inpatient stays, potential prescribing omissions and missed examinations. Deficiencies in vaccinations and secondary prevention were also demonstrated.

CONCLUSION

Coordination of care for multimorbid older patients in Germany is still deficient. Future healthcare arrangements should be explored with the participation of physicians and patients.

TRIAL REGISTRATION NUMBER

LoChro trial: DRKS00013904.

Polypharmacy and medicine regimens in older adults in residential aged care

OBJECTIVE

To describe medicines regimens used by older people living in residential aged care facilities (RACFs).

MATERIALS AND METHODS

This cross-sectional study presents baseline data from a randomised controlled trial in seventeen Australian RACFs that recruited residents aged 65 years and older at the participating facilities. The main outcome measures were to evaluation of medicines utilisation, including the number of medicines, medicine regimen complexity, potential under-prescribing and high-risk prescribing (prescribing cascades, anticholinergic or sedative medicines or other potentially inappropriate medicines) with data analysed descriptively.

RESULTS

Medicines regimens were analysed for 303 residents (76% female) with a mean age of 85.0 ± 7.5 years, of whom the majority were living with dementia (72%). Residents were prescribed an average of 10.3 ± 4.5 regular medicines daily. Most participants (85%) had highly complex regimens. Most residents (92%) were exposed to polypharmacy (five or more medicines). Nearly all, 302 (98%) residents had at least one marker of potentially suboptimal prescribing. At least one instance of potential under-prescribing was identified in 86% of residents. At least one instance of high-risk prescribing was identified in 81% of residents including 16% of participants with at least one potential prescribing cascade.

CONCLUSION(S)

Potentially suboptimal prescribing affected almost all residents in this study, and most had highly complex medicines regimens. If generalisable, these findings indicate most older people in RACFs may be at risk of medicines-related harm from suboptimal prescribing, in addition to the burden of administration of complex medicines regimens for facility staff and residents.

A combination of Beers and STOPP criteria better detects potentially inappropriate medications use among older hospitalized patients with chronic diseases and polypharmacy: a multicenter cross-sectional study

BACKGROUND

Research on potentially inappropriate medications (PIM) and medication-related problems (MRP) among the Chinese population with chronic diseases and polypharmacy is insufficient.

OBJECTIVES

This study aimed to investigate the prevalence of PIM and MRP among older Chinese hospitalized patients with chronic diseases and polypharmacy and analyze the associated factors.

METHODS

A retrospective cross-sectional study was conducted in five tertiary hospitals in Beijing. Patients aged ≥ 65 years with at least one chronic disease and taking at least five or more medications were included. Data were extracted from the hospitals' electronic medical record systems. PIM was evaluated according to the 2015 Beers criteria and the 2014 Screening Tool of Older Persons' Prescriptions (STOPP) criteria. MRPs were assessed and classified according to the Helper-Strand classification system. The prevalence of PIM and MRP and related factors were analyzed.

RESULTS

A total of 852 cases were included. The prevalence of PIM was 85.3% and 59.7% based on the Beers criteria and the STOPP criteria. A total of 456 MRPs occurred in 247 patients. The most prevalent MRP categories were dosages that were too low and unnecessary medication therapies. Hyperpolypharmacy (taking ≥ 10 drugs) (odds ratio OR 3.736, 95% confidence interval CI 1.541-9.058, P = 0.004) and suffering from coronary heart disease (OR 2.620, 95%CI 1.090-6.297, P = 0.031) were the influencing factors of inappropriate prescribing (the presence of either PIM or MRP in a patient).

CONCLUSION

PIM and MRP were prevalent in older patients with chronic disease and polypharmacy in Chinese hospitals. More interventions are urgently needed to reduce PIM use and improve the quality of drug therapies.

Comprehensive Multimorbidity Patterns in Older Patients Are Associated with Quality Indicators of Medication-MoPIM Cohort Study

Multimorbidity is increasing and poses a challenge to the clinical management of patients with multiple conditions and drug prescriptions. The objectives of this work are to evaluate if multimorbidity patterns are associated with quality indicators of medication: potentially inappropriate prescribing (PIP) or adverse drug reactions (ADRs). A multicentre prospective cohort study was conducted including 740 older (≥65 years) patients hospitalised due to chronic pathology exacerbation. Sociodemographic, clinical and medication related variables (polypharmacy, PIP according to STOPP/START criteria, ADRs) were collected. Bivariate analyses were performed comparing previously identified multimorbidity clusters (osteoarticular, psychogeriatric, minor chronic disease, cardiorespiratory) to presence, number or specific types of PIP or ADRs. Significant associations were found in all clusters. The osteoarticular cluster presented the highest prevalence of PIP (94.9%) and ADRs (48.2%), mostly related to anxiolytics and antihypertensives, followed by the minor chronic disease cluster, associated with ADRs caused by antihypertensives and insulin. The psychogeriatric cluster presented PIP and ADRs of neuroleptics and the cardiorespiratory cluster indicators were better overall. In conclusion, the associations that were found reinforce the existence of multimorbidity patterns and support specific medication review actions according to each patient profile. Thus, determining the relationship between multimorbidity profiles and quality indicators of medication could help optimise healthcare processes. Trial registration number: NCT02830425.

Under-prescription of medications in older adults according to START criteria: A cross-sectional study in Lebanon

Background and Aims

Under-prescription is defined as the exclusion of medications indicated for the treatment of certain conditions without any rationale for not prescribing them. The under-prescription of medications is highly prevalent among older adults (≥65 years) receiving polypharmacy. This study aimed to assess the prevalence of the under-prescription of medications using the Screening Tool to Alert to Right Treatment (START) criteria version 2 and to identify the predictors of having potential prescribing omissions (PPOs).

Methods

This cross-sectional, face-to-face interview study was carried out between September 2021 and February 2022. The study comprised community-dwelling older adults taking at least one medication on a regular basis. The study questionnaire included the patients' demographics, clinical data, and comorbidities. PPOs were identified using the START criteria. The χ 2 test was used to assess the association between under-prescription of medication and the demographic/clinical variables. Multivariable logistic regression was performed to explore factors associated with under-prescription of medications as the dependent variable and taking all variables that showed a p < 0.05 in the bivariate analysis as independent.

Results

A total of 444 older adults agreed to participate in this study. The mean age of participants was 71 ± 8.6; the majority of them, 305 (68.7%), were men. Polypharmacy was present in 261 patients (58.8%) and underprescribing of medications in 260 patients (58.6%). The highest percentage of under-prescribing of medications was reported with statins in 115 patients (44.2%) followed by aspirin in 93 (35.7%), and angiotensin-converting enzyme inhibitors in 61 (23.4%). The results of the multivariable analysis showed that patients with underprescribed medications had higher odds of polypharmacy (odds ratio [OR]: 2.015, confidence interval [CI] 95% 1.362-2.980, p < 0.001) and higher Charlson Comorbidity Index (OR 2.807, CI 95% 1.463-5.85, p = 0.02).

Conclusion

The present findings highlight that PPOs are highly prevalent among community-dwelling older adults in Lebanon. Multimorbidity and polypharmacy were the identified predictors for under-prescription of medications in this population.

The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review

In the context of an ageing population, the burden of disease and medicine use is also expected to increase. As such, medicine safety and preventing avoidable medicine-related harm are major public health concerns, requiring further research. Potentially suboptimal medicine regimens is an umbrella term that captures a range of indicators that may increase the risk of medicine-related harm, including polypharmacy, underprescribing and high-risk prescribing, such as prescribing potentially inappropriate medicines. This narrative review aims to provide a background and broad overview of the patterns and implications of potentially suboptimal medicine regimens among older adults. Original research published between 1990 and 2021 was searched for in MEDLINE, using key search terms including polypharmacy, inappropriate prescribing, potentially inappropriate medication lists, medication errors, drug interactions and drug prescriptions, along with manual checking of reference lists. The review summarizes the prevalence, risk factors and clinical outcomes of polypharmacy, underprescribing and potentially inappropriate medicines. A synthesis of the evidence regarding the longitudinal patterns of polypharmacy is also provided. With an overview of the existing literature, we highlight a number of key gaps in the literature. Directions for future research may include a longitudinal investigation into the risk factors and outcomes of extended polypharmacy, research focusing on the patterns and implications of underprescribing and studies that evaluate the applicability of tools measuring potentially inappropriate medicines to study settings.

Facing the challenge of polypharmacy when prescribing for older people with cardiovascular disease. A review by the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy

Population ageing has resulted in an increasing number of older people living with chronic diseases (multimorbidity) requiring five or more medications daily (polypharmacy). Ageing produces important changes in the cardiovascular system and represents the most potent single cardiovascular risk factor. Cardiovascular diseases (CVDs) constitute the greatest burden for older people, their caregivers, and healthcare systems. Cardiovascular pharmacotherapy in older people is complex because age-related changes in body composition, organ function, homeostatic mechanisms, and comorbidities modify the pharmacokinetic and pharmacodynamic properties of many commonly used cardiovascular and non-cardiovascular drugs. Additionally, polypharmacy increases the risk of adverse drug reactions and drug interactions, which in turn can lead to increased morbi-mortality and healthcare costs. Unfortunately, evidence of drug efficacy and safety in older people with multimorbidity and polypharmacy is limited because these individuals are frequently underrepresented/excluded from clinical trials. Moreover, clinical guidelines are largely written with a single-disease focus and only occasionally address the issue of coordination of care, when and how to discontinue treatments, if required, or how to prioritize recommendations for patients with multimorbidity and polypharmacy. This review analyses the main challenges confronting healthcare professionals when prescribing in older people with CVD, multimorbidity, and polypharmacy. Our goal is to provide information that can contribute to improving drug prescribing, efficacy, and safety, as well as drug adherence and clinical outcomes.

Medication Use and Costs Among Older Adults Aged 90 Years and Older in Italy

Older adults are often affected by multiple chronic conditions and experience geriatric syndromes that may affect the risk/benefit profile of medications. Little is known about the use of such medications in the older population. This article describes medication use and costs in Italian adults aged ≥90 years. Data from the 2019 Pharmaceutical Prescriptions database, concerning data on medications reimbursed by the Italian National Health Service, were analyzed in terms of prevalence and amount of use expressed as defined daily dose/1,000 users (DDD/1,000 users/day), accounting for different age-groups and sex. All individuals aged ≥90 years used at least one medication, with a mean number of 3128 DDD/1,000 users/day corresponding to an annual cost of 683 euros per user. Both use and costs linearly decreased with increasing age, with men accounting for a higher amount of DDD/1,000 users and costs than women across all age-groups. Antihypertensives (1330 DDD/1,000 inhabitants), antiplatelet agents (337 DDD/1,000 inhabitants), medications for peptic ulcer and gastroesophageal reflux (328 DDD/1,000 inhabitants), and lipid-lowering agents (166 DDD/1,000 inhabitants) were the most frequently used medications. We observed a progressive decrease in the usage of the majority of medications with increasing age, with the exception of antibiotics and antipsychotics. Individuals aged ≥90 years used a lower DDD/1,000 users, with an associated decrease in annual costs. The persistent use of preventive medications highlights the potential lack of awareness regarding medication rationalization and guidance for optimizing prescriptions. Our findings highlight the need for further initiatives to improve medications’ appropriateness in these older age-groups.

Intervention and in-hospital pharmacoterapies in octogenarian with acute coronary syndrome: a 10-year retrospective analysis of the Malaysian National Cardiovascular Database (NCVD) registry

BACKGROUND

Octogenarians and beyond have often been neglected in the populational study of disease despite being at the highest point of non-modifiable disease risk burden and the fastest-growing age group for the past decade. This study examined the characteristics and in-hospital management of octogenarian patients with acute coronary syndrome (ACS) in a multi-ethnic, middle-income country in South East Asia.

METHOD

This retrospective study utilised the Malaysian National Cardiovascular Disease- ACS (NCVD-ACS) registry. Consecutive patient data of those ≥80 years old admitted with ACS at 24 participating hospitals from 2008 to 2017 (n = 3162) were identified. Demographics, in-hospital intervention, and evidence-based pharmacotherapies over the 10-years were examined and compared across groups of interests using the Chi-square test. Multivariate logistic regression was used to calculate the adjusted odds ratio of receiving individual therapies according to patients' characteristics.

RESULTS

Octogenarians made up 3.8% of patients with ACS in the NCVD-ACS registry (mean age = 84, SD ± 3.6) from 2008 until 2017. The largest ethnic group was Chinese (44%). Most octogenarians (95%) have multiple cardiovascular risk factors, with hypertension (82%) being the main. Non-ST-elevation myocardial infarction (NSTEMI) predominated (38%, p < 0.001). Within the 10-year, there were positive increments in cardiovascular intervention and pharmacotherapies. Only 10% of octogenarians with ACS underwent percutaneous coronary intervention (PCI), the majority being STEMI patients (17.5%; p < 0.05). More than 80% were prescribed aspirin (91.3%) either alone or combined, dual antiplatelet therapy (DAPT) (83.3%), anticoagulants (89.7%) and statins (89.6%), while less being prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (47.6%) and beta-blockers (43.0%). Men were more likely to receive PCI than women (adjusted Odds Ratio (aOR): 0.698; 95% CI: 0.490-0.993). NSTEMI (aOR = 0.402, 95% CI: 0.278-0.583) and unstable angina (UA) (aOR = 0.229, 95% CI: 0.143-0.366) were less likely to receive PCI but more likely given anticoagulants (NSTEMI, aOR = 1.543, 95% CI: 1.111-2.142; UA, aOR = 1.610, 95% CI: 1.120-2.314) than STEMI. The presence of cardiovascular risk factors and comorbidities influences management.

CONCLUSION

Octogenarians with ACS in this country were mainly treated with cardiovascular pharmacotherapies. As the number of octogenarians with ACS will continue to increase, the country needs to embrace the increasing use of PCI in this group of patients.

Pharmacological treatment after acute coronary syndrome: Baseline clinical characteristics and gender differences in a population-based cohort study

OBJECTIVE

To describe baseline socio-demographic and clinical characteristics and drugs prescribed for secondary prevention after a first episode of ACS and to assess differences between men and women.

SETTING

PHC in Catalonia.

DATA SOURCE

SIDIAP (Information System for Research in Primary Care).

PARTICIPANTS

Patients who suffered an ACS during 2009-2016 and followed-up in PHC centres of the Catalan Health Institute in Catalonia.

INTERVENTIONS

Not applicable.

MAIN MEASURES

Socio-demographic and clinical characteristics at baseline: sex, age, socioeconomic index, toxic habits, comorbidities, study drugs (prescribed for cardiovascular secondary prevention: antiplatelets, betablockers, statins, drugs acting on the renin-angiotensin system) and comedications.

RESULTS

8071 patients included, 71.3% of them were men and 80.2% had an acute myocardial infarction. Their mean age was 65.3 and women were older than men. The most frequent comorbidities were hypertension, dyslipidaemia and diabetes and they were more common in women. Antiplatelets (91.3%) and statins (85.7%) were the study drugs most prescribed. The uses of all comedications were significantly higher in women, except for nitrates. The combination of four study groups was initially prescribed in 47.7% of patients and combination of beta-blockers, statins and antiplatelets was prescribed in 18.4%. More men than women received all recommended pharmacological groups.

CONCLUSION

Women were older, had more comorbidities and received more comedications. Most patients were treated with a combination of four or three study drugs for secondary prevention. Men initiated more drug treatments for secondary prevention and dual antiplatelet therapy than women.

EUPAS REGISTER

EUPAS19017.

Prescribing at 95 years of age: cross-sectional findings from the Newcastle 85+ study

BACKGROUND

Previous research has examined prescribing amongst 85-year-olds in English primary care, but less is known about prescribing amongst 95-year-olds in spite of population ageing.

AIM

We describe the most commonly prescribed medicines in a cohort of 95-year-olds, using 10-year follow-up data from the Newcastle 85+ Study (n = 90).

METHOD

A total of 1040 participants were recruited to the Newcastle 85+ Study through general practices at 85-years of age, and 90 surviving participants were re-contacted and assessed at 95-years of age. Prescribed medications from general practice medical records were examined through cross-tabulations and classified as preventative or for symptom control based on their customary usage.

RESULTS

Preventative medications with unclear evidence of benefit such as statins (36.7%), aspirin (21.1%) and bisphosphonates (18.9%) were frequently prescribed.

CONCLUSIONS

Future research in a larger clinical dataset could investigate this preliminary trend, which suggests that benefit/risk information for preventive medication, and evidence for deprescribing, is needed in the very old.

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.

Potentially Inappropriate Medications and Potential Prescribing Omissions in Elderly Patients Receiving Post-Acute and Long-Term Care: Application of Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment Criteria

Background: Screening Tool of Older People's Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria have been used to detect potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs). These criteria were applied to geriatric Portuguese patients receiving post-acute and long-term care to assess the prevalence and predictors of PIMs and PPOs. Methods: An observational, retrospective, cross-sectional and multicenter study was performed in 161 patients (aged ≥65 years) from eight Units for Integrated Continuous Care. Results: In these studied patients (mean age: 81.6, 64% female, median number of medications: 9) PIMs were detected in 85.1% and PPOs in 81.4% of patients. While PIMs mainly involved the central nervous system and psychotropic drugs (66.5%), PPOs were mostly related to musculoskeletal system (55.3%) and cardiovascular (39.8%) system. A subsequent analysis with logistic regression found the female gender, the hospital provenience, and the number of medications as predictors of PIMs. Predictors of PPOs were the Charlson Comorbidity Index and history of recent fractures. Conclusion: PIMs and PPOs were highly prevalent in the studied patients receiving post-acute and long-term care in Units for Integrated Continuous Care. Therefore, STOPP/START criteria might be an effective tool for improving prescribing quality and clinical outcomes in these frail elderly patients.

STOPP/START interventions to improve medicines management for people aged 65 years and over: a realist synthesis

Background

Drug-related problems and potentially inappropriate prescribing impose a huge burden on patients and the health-care system. The most widely used tools for appropriate prescription in older adults in England and in other European countries are the Screening Tool of Older People’s Prescriptions (STOPP)/Screening Tool to Alert to the Right Treatment (START) tools. STOPP/START tools support medicines optimisation for older adults.

Objectives

To identify, test and refine the programme theories underlying how interventions based on the STOPP/START tools are intended to work, for whom, in what circumstances and why, as well as the resource use and cost requirements or impacts.

Design

A realist synthesis.

Setting

Primary care, hospital care and nursing homes.

Patients

Patients aged ≥ 65 years.

Interventions

Any intervention based on the use of the STOPP/START tools.

Review methods

Database and web-searching was carried out to retrieve relevant evidence to identify and test programme theories about how interventions based on the use of the STOPP/START tools work. A project reference group made up of health-care professionals, NHS decision-makers, older people, carers and members of the public was set up. In phase 1 we identified programme theories about STOPP/START interventions on how, for whom, in what contexts and why they are intended to work. We searched the peer-reviewed and grey literature to identify documents relevant to the research questions. We interviewed experts in the field in our reference group to gain input on our list of candidate context–mechanism–outcome configurations, to identify additional context–mechanism–outcome configurations and to identify additional literature and/or relevant concepts. In phase 2 we reviewed and synthesised relevant published and unpublished empirical evidence and tested the programme theories using evidence from a larger set of empirical studies.

Results

We developed a single logic model structured around three key mechanisms: (1) personalisation, (2) systematisation and (3) evidence implementation. Personalisation: STOPP/START-based interventions are based on shared decision-making, taking into account patient preferences, experiences and expectations (mechanisms), leading to increased patient awareness, adherence, satisfaction, empowerment and quality of life (outcomes). Systematisation: STOPP/START tools provide a standardised/systematic approach for medication reviews (mechanisms), leading to changes in professional and organisational culture and burden/costs (outcomes). Evidence implementation: delivery of STOPP/START-based interventions is based on the implementation of best evidence (mechanisms), reducing adverse outcomes through appropriate prescribing/deprescribing (outcomes). For theory testing, we identified 40 studies of the impact of STOPP/START-based interventions in hospital settings, nursing homes, primary care and community pharmacies. Most of the interventions used multiple mechanisms. We found support for the impact of the personalisation and evidence implementation mechanisms on selected outcome variables, but similar impact was achieved by interventions not relying on these mechanisms. We also observed that the impact of interventions was linked to the proximity of the selected outcomes to the intervention in the logic model, resulting in a clearer benefit for appropriateness of prescribing, adverse drug events and prescription costs.

Limitations

None of the available studies had been explicitly designed for evaluating underlying causal mechanisms, and qualitative information was sparse.

Conclusions

No particular configuration of the interventions is associated with a greater likelihood of improved outcomes in given settings.

Study registration

This study is registered as PROSPERO CRD42018110795.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 23. See the NIHR Journals Library website for further project information.

Health, social care and technological interventions to improve functional ability of older adults living at home: An evidence and gap map

Background

By 2030, the global population of people older than 60 years is expected to be higher than the number of children under 10 years, resulting in major health and social care system implications worldwide. Without a supportive environment, whether social or built, diminished functional ability may arise in older people. Functional ability comprises an individual's intrinsic capacity and people's interaction with their environment enabling them to be and do what they value.

Objectives

This evidence and gap map aims to identify primary studies and systematic reviews of health and social support services as well as assistive devices designed to support functional ability among older adults living at home or in other places of residence.

Search Methods

We systematically searched from inception to August 2018 in: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, PsycINFO, AgeLine, Campbell Library, ASSIA, Social Science Citation Index and Social Policy & Practice. We conducted a focused search for grey literature and protocols of studies (e.g., ProQuest Theses and Dissertation Global, conference abstract databases, Help Age, PROSPERO, Cochrane and Campbell libraries and ClinicalTrials.gov).

Selection Criteria

Screening and data extraction were performed independently in duplicate according to our intervention and outcome framework. We included completed and on-going systematic reviews and randomized controlled trials of effectiveness on health and social support services provided at home, assistive products and technology for personal indoor and outdoor mobility and transportation as well as design, construction and building products and technology of buildings for private use such as wheelchairs, and ramps.

Data Collection and Analysis

We coded interventions and outcomes, and the number of studies that assessed health inequities across equity factors. We mapped outcomes based on the International Classification of Function, Disability and Health (ICF) adapted categories: intrinsic capacities (body function and structures) and functional abilities (activities). We assessed methodological quality of systematic reviews using the AMSTAR II checklist.

Main Results

After de-duplication, 10,783 records were screened. The map includes 548 studies (120 systematic reviews and 428 randomized controlled trials). Interventions and outcomes were classified using domains from the International Classification of Function, Disability and Health (ICF) framework. Most systematic reviews (n = 71, 59%) were rated low or critically low for methodological quality.The most common interventions were home-based rehabilitation for older adults (n = 276) and home-based health services for disease prevention (n = 233), mostly delivered by visiting healthcare professionals (n = 474). There was a relative paucity of studies on personal mobility, building adaptations, family support, personal support and befriending or friendly visits. The most measured intrinsic capacity domains were mental function (n = 269) and neuromusculoskeletal function (n = 164). The most measured outcomes for functional ability were basic needs (n = 277) and mobility (n = 160). There were few studies which evaluated outcome domains of social participation, financial security, ability to maintain relationships and communication.There was a lack of studies in low- and middle-income countries (LMICs) and a gap in the assessment of health equity issues.

Authors' Conclusions

There is substantial evidence for interventions to promote functional ability in older adults at home including mostly home-based rehabilitation for older adults and home-based health services for disease prevention. Remotely delivered home-based services are of greater importance to policy-makers and practitioners in the context of the COVID-19 pandemic. This map of studies published prior to the pandemic provides an initial resource to identify relevant home-based services which may be of interest for policy-makers and practitioners, such as home-based rehabilitation and social support, although these interventions would likely require further adaptation for online delivery during the COVID-19 pandemic. There is a need to strengthen assessment of social support and mobility interventions and outcomes related to making decisions, building relationships, financial security, and communication in future studies. More studies are needed to assess LMIC contexts and health equity issues.

Cardiovascular care of older adults

Age is an independent risk factor for cardiovascular disease. With the accelerated growth of the population of older adults, geriatric and cardiac care are becoming increasingly entwined. Although cardiovascular disease in younger adults often occurs as an isolated problem, it is more likely to occur in combination with clinical challenges related to age in older patients. Management of cardiovascular disease is transmuted by the context of multimorbidity, frailty, polypharmacy, cognitive dysfunction, functional decline, and other complexities of age. This means that additional insight and skills are needed to manage a broader range of relevant problems in older patients with cardiovascular disease. This review covers geriatric conditions that are relevant when treating older adults with cardiovascular disease, particularly management considerations. Traditional practice guidelines are generally well suited for robust older adults, but many others benefit from a relatively more personalized therapeutic approach that allows for a range of medical circumstances and idiosyncratic goals of care. This requires weighing of risks and benefits amidst the patient's aggregate clinical status and the ability to communicate effectively about this with patients and, where appropriate, their care givers in a process of shared decision making. Such a personalized approach can be particularly gratifying, as it provides opportunities to optimize an older patient's function and quality of life at a time in life when these often become foremost therapeutic priorities.

Prevalence of Polypharmacy and Risks of Potentially Inappropriate Medication Use in the Older Population in a Developing Country: A Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Polypharmacy and potentially inappropriate medication (PIM) use in older populations (65+ years) have not yet been investigated by meta-analyses in developing countries. This systematic literature review and meta-analysis aimed to investigate the prevalence of polypharmacy and PIM use and major risk factors associated with PIM prescribing in older adults in Ethiopia.

METHODS

We searched PubMed/MEDLINE, Scopus, Embase, and Google Scholar databases to identify relevant studies published between January 1990 and October 2020. Observational studies reporting the prevalence and association of risk factors with polypharmacy and PIM use in the older population were meta-analyzed. A multilevel meta-analysis was conducted to pool the prevalence estimates, and the risk of PIM use was reported as a relative risk (RR) with a 95% confidence interval (CI).

RESULTS

We identified by systematic literature review 404 articles. Of those, 8 studies fulfilled inclusion criteria, comprising a total sample of 2,608 participants. The overall prevalence of polypharmacy and PIM use pooled by meta-analysis in the Ethiopian older population was 33 and 37%, respectively. The risk factors of PIM use were analyzed in the meta-analysis (particularly polymorbidity, polypharmacy, gender, and older age), and only older age of 65+ (RR: 1.71, 95% CI: 1.16-2.51) was significantly associated with PIM use.

CONCLUSION

This first meta-analysis from a developing country revealed a high prevalence of polypharmacy and PIM use in the Ethiopian older population. There was no awareness about the risk of PIMs in patients with polypharmacy and polymorbidity, and older age significantly predicted PIM use. Interventions ensuring rational geriatric pharmacotherapy are essential in developing countries in order to reduce the expected burden of PIM-related geriatric morbidity, higher costs, and mortality.

Impacts of Pharmacists-Managed Oncology Outpatient Clinic on Resolving Drug-Related Problems in Ambulatory Neoplasm Patients: A Prospective Study in China

Pharmacists are health care professionals who are actively involved in identifying and solving drug-related problems (DRPs) in neoplasm patients. However, the effectiveness of pharmaceutical services at outpatient clinic for neoplasm patients have not been reported in China. This study aims to describe and investigate the impacts of pharmacists-managed oncology outpatient clinic on ambulatory neoplasm patients. We performed a descriptive, prospective study from June 6, 2018 to June 6, 2020. Firstly, we established a pharmacists-managed oncology outpatient clinic and a Pharmacists Work System of Medication Therapy Management (MTM) software with the cooperation of oncologists, pharmacists and software engineers in 2018. Subjects were neoplasm patients who visited the pharmacists-managed outpatient clinic. The pharmacists performed a comprehensive assessment of the patient’s medication and made planned interventions based on the DRPs identified. A total of 215 eligible patients with 707 visits were enrolled and recorded in the MTM software. A total of 316 DRPs (1.47 per patient) were identified. Adverse reactions, non-adherence, untreated indication, and drug interactions were the leading DRPs. 261 (82.6%) of the identified DRPs had been confirmed as resolved and 104 (78.2%) of adverse reactions were improved following pharmacist interventions and 2 to 3 course follow-up. Of the 382 planned interventions, 345 (90.3%) were accepted by patients or physicians. This is the first pharmacists-managed oncology outpatient clinic to describe the type of DRPs in neoplasm patients and evaluate the effectiveness of pharmacist interventions in China. Pharmacist interventions were efficacious in resolving DRPs and improving adverse reactions. We confirmed that pharmacists have an important role in ambulatory neoplasm patients care.

Age-Based Variations in the Gut Microbiome of the Shennongjia (Hubei) Golden Snub-Nosed Monkey (Rhinopithecus roxellana hubeiensis)

The gut microbiota represents a source of genetic and metabolic diversity of a complex polymicrobial ecosystem within its host. To investigate age-based variations of the gut microbiota among Shennongjia golden snub-nosed monkeys (Rhinopithecus roxellana hubeiensis), we characterized the microbial species in fecal samples from 18 Shennongjia golden snub-nosed monkeys evenly pooled into 3 aged groups (Group 1, 1-3 years; Group 2, 5-8 years; Group 3, above 12 years) in Shennongjia, Hubei Province, China. Genomic DNA was extracted from fecal samples, and the 16S rRNA gene V4 region was sequenced using the Illumina high-throughput MiSeq platform PE250. A total of 28 microbial phyla were identified in the gut microbiome of these monkeys with the ten most abundant phyla (i.e., Firmicutes, Bacteroidetes, Verrucomicrobia, Spirochaetes, Tenericutes, Proteobacteria, Planctomycetes, Fibrobacteres, Cyanobacteria, and Euryarchaeota). A total of 1,469 (of 16 phyla and 166 genera), 1,381 (of 16 phyla and 157 genera), and 1,931 (of 19 phyla and 190 genera) operational taxonomic units (OTUs) were revealed in Groups 1, 2, and 3, respectively, with Group 3 containing the most diverse groups of OTUs as revealed by the species relative abundance clustering analysis. These results suggest that the gut microbiota in these monkeys maintain a dynamic status, starting from the early developmental stages of life with the species relative abundance increasing with age. This is the first study to comprehensively characterize the gut microbiota and provide valuable information for monitoring the health and nutritional needs of this endangered primate at different ages.

Underprescription of medications in older adults: causes, consequences and solutions-a narrative review

PURPOSE

Under-prescription is defined as the omission of a medication that is indicated for the treatment of a condition or a disease, without any valid reason for not prescribing it. The aim of this review is to provide an updated overview of under-prescription, summarizing the available evidence concerning its prevalence, causes, consequences and potential interventions to reduce it.

METHODS

A PubMed search was performed, using the following keywords: under-prescription; under-treatment; prescribing omission; older adults; polypharmacy; cardiovascular drugs; osteoporosis; anticoagulant. The list of articles was evaluated by two authors who selected the most relevant of them. The reference lists of retrieved articles were screened for additional pertinent studies.

RESULTS

Although several pharmacological therapies are safe and effective in older patients, under-prescription remains widespread in the older population, with a prevalence ranging from 22 to 70%. Several drugs are underused, including cardiovascular, oral anticoagulant and anti-osteoporotic drugs. Many factors are associated with under-prescription, e.g. multi-morbidity, polypharmacy, dementia, frailty, risk of adverse drug events, absence of specific clinical trials in older patients and economic factors. Under-prescription is associated with negative consequences, such as higher risk of cardiovascular events, worsening disability, hospitalization and death. The implementation of explicit criteria for under-prescription, the use of the comprehensive geriatric assessment by geriatricians, and the involvement of a clinical pharmacist seem to be promising options to reduce under-prescription.

CONCLUSION

Under-prescription remains widespread in the older population. Further studies should be performed, to provide a better comprehension of this phenomenon and to confirm the efficacy of corrective interventions.

Potentially inappropriate prescribing according to STOPP-2 criteria among elderly patients in an acute medical department: An observational study of prevalence and predictive factors

OBJECTIVE

The aim of the study was to assess the prevalence and factors associated with potentially inappropriate medication use in elderly patients hospitalized in an acute medical unit.

METHODS

It is a prospective observational study carried out in the acute medical unit of Ibn Sina University Hospital located in Rabat, Morocco. The study sample consisted of all hospitalized patients aged ≥65years. Data collection was performed by a clinical pharmacist during an interview with the patient, at the multidisciplinary team meeting and from the patient's medical records. Medication use was assessed everyday from admission to discharge. The frequency of potentially inappropriate medication (PIM) was evaluated using The Screening Tool of Older Person's Prescriptions (STOPP) criteria version 2.

RESULTS

The study involved 123 elderly inpatients aged 75±7 years old. In total, 55 patients (44.7%) used≥1 PIM. The highest prevalence of PIMs was in relation with concomitant use of two or more drugs with anticholinergic properties (16%). In adjusted multivariate analysis, the following parameters were independently associated with PIM use: length of stay at the acute medical unit (OR 1.12; 95% CI 1.00-1.20), and number of pre-admission drugs (OR 1.30; 95% CI 1.00-1.60).

CONCLUSION

Half of the elderly population received at least one PIM identified by the STOPP criteria. Inadequacy of prescription was associated with the number of pre-admission drugs and the length of stay. Assessing medication during conciliation and enhanced drugs monitoring at discharge especially for patients with a longer stay can be an important strategy for minimizing PIM use.

‘I've never given it a thought’: older men's experiences with and perceptions of ageism during interactions with physicians

The subjective experience of ageism among older men has received little research attention. This study examines older Canadian men's experiences with and perceptions of ageism during interactions with physicians. In-depth, face-to-face interviews were conducted with 21 men aged 55 years and over. The findings indicate a seeming lack of awareness of ageism among many, and many did not believe ageism was likely to occur during patient–physician interaction. Negative stereotyping of older patients was common. A large majority of the participants reported that they had not personally experienced ageism during a medical encounter, nor were they concerned about it. Numerous rationales were proffered as explanations of why a particular participant had not experienced ageism and who was more likely to be a target.

Factors influencing trends in opioid prescribing for older people: a scoping review

Aim:

The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people.

Background:

Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group.

Methods:

This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends.

Findings:

A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA.

Conclusions:

A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.

Patient outcomes from implementing an enhanced services pharmacy network

OBJECTIVE

To evaluate the effect of implementing a network of community pharmacies on medication adherence, health service utilization, and health care spending.

DESIGN

Quasi-experimental difference-in-difference analysis with a nonequivalent control group.

SETTING AND PARTICIPANTS

Eligible Medicaid-enrolled patients in North Carolina were attributed to intervention pharmacies between March 2015 and December 2016. A control group was propensity score-matched. Interventions consisted of enhanced services and a more intensive, comprehensive initial pharmacy assessment (CIPA).

OUTCOME MEASURES

Outcomes included hospitalizations; emergency department (ED) visits; health care spending for total medical, inpatient, outpatient, and ED services; and adherence to renin-angiotensin system antagonists (RASA), statins, noninsulin diabetes medications (NIDM), and multiple medications for chronic conditions (MMCC).

RESULTS

There were 31,509 patients who met eligibility criteria and were attributed to a participating pharmacy. Of these, 3897 received a CIPA. Before matching, patients attributed to participating pharmacies had greater Medicaid enrollment through aged, blind, or disabled status (49.2% vs. 31.5%, P < 0.001); greater case management (10.3% vs. 7%, P < 0.001); and worse rates of chronic disease (P < 0.001). Successful matching removed these differences. Adherence to RASA medications and MMCC increased by 9.5% and 10.3% (P < 0.05), respectively. Adherence did not change for statins and NIDM. The analysis also revealed a slower decline in average total medical spending of 5.7% (P < 0.01) relative to the control group over the same period, owed to a 9.6% (P < 0.001) slower decline in outpatient spending. ED utilization also decreased more slowly relative to controls by 4.8% (P < 0.05) following the intervention.

CONCLUSION

The pharmacy intervention resulted in a statistically significant improvement in medication adherence to RASA and multiple chronic medications, but did not change or may have worsened utilization and spending outcomes. More research is needed to explore patient selection and variation in implementation and heterogeneity of treatment effects when evaluating pharmacy interventions.

Bridging the intergenerational gap: the outcomes of a student-initiated, longitudinal, inter-professional, inter-generational home visit program

BACKGROUND

Older persons consume disproportionately more healthcare resources than younger persons. Tri-Generational HomeCare (TriGen), a service-learning program, aims to reduce hospital admission rates amongst older patients with frequent admissions. The authors evaluated the educational and patient outcomes of TriGen.

METHODS

Teams consisting of healthcare undergraduates and secondary school (SS) students - performed fortnightly home visits to patients over 6 months. Self-administered scales were used to evaluate the educational outcomes in knowledge and attitudes towards the older people and nine domains of soft skills pre- and post-intervention. Patients' reported satisfaction and clinical outcomes were also assessed.

RESULTS

Two hundred twenty-six healthcare undergraduates and 359 SS students participated in the program from 2015 to 2018. Response rates were 80.1 and 62.4% respectively. One hundred six patients participated in TriGen. There was a significant increase in Kogan's Attitudes towards Old People Scale (KOP) scores for healthcare undergraduates and SS students with a mean increase of 12.8 (95%CI: 9.5-16.2, p <  0.001) and 8.3 (95%CI: 6.2-10.3, p <  0.001) respectively. There was a significant increase in Palmore Facts on Aging Quiz (PFAQ) score for SS students but not for healthcare undergraduates. Most volunteers reported that TriGen was beneficial across all nine domains assessed. There was also a significant decrease in hospital admission rates (p = 0.006) and emergency department visits (p = 0.004) during the 6-month period before and after the program. Fifty-one patients answered the patient feedback survey. Of this, more than 80% reported feeling less lonely and happier.

CONCLUSION

TriGen, a student-initiated, longitudinal, inter-generational service-learning program consisting of SS students and healthcare undergraduates can reduce ageism, develop soft skills, inculcate values amongst SS students and healthcare undergraduates. In addition, TriGen potentially reduces hospital admissions and emergency department visits, and loneliness amongst frequently admitted older patients.

Clinical Response to Real-Time Patient-Reported Diabetic Peripheral Neuropathy Symptoms

INTRODUCTION

To assess clinician response to real-time patient-reported data about diabetic peripheral neuropathy (DPN) symptoms, we analyzed DPN diagnosis and treatment patterns after administration of a 4-question symptom questionnaire in a large vertically integrated health care system.

METHODS

Retrospective cohort study to analyze data from 160,852 patients screened for DPN symptoms from April 2012 to March 2014. Electronic medical record data were used to study changes in DPN diagnosis, treatment initiation, and treatment intensification. We used logistic regression to study the association of patient characteristics with the odds of clinical response.

RESULTS

Of patients queried, 50,684 (31.5%) reported symptoms. Patients reporting DPN symptoms experienced a greater increase in new DPN diagnoses (16 percentage points; p < 0.0001) and medication use (4 percentage points; p < 0.0001) compared with those denying symptoms. Among patients reporting symptoms, women and nonwhite patients were less likely to receive a DPN diagnosis, whereas older patients were more likely to receive a DPN diagnosis. Overall, patients who were older, were Asian (hazard ratio = 0.67, 95% confidence interval = 0.63-0.77), and had lower socioeconomic status (hazard ratio = 0.89, 95% confidence interval = 0.80-0.99) were less likely to be treated. However, these racial and socioeconomic differences were not statistically significant for patients with preexisting DPN diagnoses.

CONCLUSION

Patients' real-time reports of DPN symptoms were associated with increased clinical activity. Patient- and clinician-level factors associated with the likelihood of receiving a DPN diagnosis need further study because a formal diagnosis may be associated with more equitable treatment.

PROTOCOL: Health, social care and technological interventions to improve functional ability of older adults: Evidence and gap map

This is a protocol for a Campbell Evidence and Gap Map. The objectives are to identify and assess the available evidence on health, social care and technological interventions to improve functional ability among older adults.

Medication-related quality of care in residential aged care: an Australian experience

OBJECTIVE

To describe medication-related quality of care (MRQOC) for Australian aged care residents.

DESIGN

Retrospective cohort using an administrative healthcare claims database.

SETTING

Australian residential aged care.

PARTICIPANTS

A total of 17 672 aged care residents who were alive at 1 January 2013 and had been a permanent resident for at least 3 months.

MAIN OUTCOME MEASURES

Overall, 23 evidence-based MRQOC indicators which assessed the use of appropriate medications in chronic disease, exposure to high-risk medications and access to collaborative health services.

RESULTS

Key findings included underuse of recommended cardiovascular medications, such as the use of statins in cardiovascular disease (56.1%). Overuse of high-risk medications was detected for medications associated with falls (73.5%), medications with moderate to strong anticholinergic properties (46.1%), benzodiazepines (41.4%) and antipsychotics (33.2%). Collaborative health services such as medication reviews were underutilised (42.6%).

CONCLUSION

MRQOC activities in this population should be targeted at monitoring and reducing exposure to antipsychotics and benzodiazepines, improving the use of preventative medications for cardiovascular disease and improving access to collaborative health services. Similarity of suboptimal MRQOC between Australia and other countries (UK, USA, Canada and Belgium) presents an opportunity for an internationally collaborative approach to improving care for aged care residents.

Is polypharmacy an increasing burden in chronic kidney disease? The German experience

This is a commentary article describing the key findings of the German chronic kidney disease (GCKD) study and how these relate to current practice. With the GCKD study showing high levels of polypharmacy, this article discusses ways to ensure that polypharmacy is appropriate and the difficulties faced within a chronic kidney disease population. Suggestions of ways to minimize medication burden in renal patients provide some practical advice for clinicians.

Potential prescribing omissions in patients with cardiovascular disease

Aims Potential prescribing omissions (PPOs) of medications are a frequent form of inadequate prescription drug practices. The objective of this study was to identify PPOs in a sample of elderly patients with cardiovascular disease. Methods Quasi-experimental study. Data were collected from a population database. We included patients who were older than 65 years and had a diagnosis of hypertension, dyslipidaemia, diabetes mellitus, coronary heart disease, heart failure or atrial fibrillation in Colombia. PPOs were determined in a random sample of patients by the START-2 (Screening Tool to Alert doctors to Right Treatment) criteria. The impact of the PPO was determined after an educational intervention with the doctors who were responsible for treating said patients. Results A total of 630 patients, with a median age of 72 years (interquartile range: 68-78 years), were included; 56.2% were women. The most frequent diagnoses were arterial hypertension (94.1%, n = 593) and dyslipidaemia (56.5%, n = 356). We identified 100 patients (15.9%) with omissions equalling 139 PPOs, and the most common PPOs were due to a lack of angiotensin-converting enzyme inhibitors in patients associated with heart failure or coronary heart disease (n = 23, 16.5%) and a lack of statins (n = 20; 14.4%) and aspirin (n = 20; 14.4%) in coronary heart disease. Prescription adjustments were achieved in 35 patients (25.2%). Conclusions Potential prescribing omissions are common in elderly patients with cardiovascular disease. Educational interventions may contribute to a reduced PPO frequency and improve the quality of prescription drug administration.

The association between polypharmacy and adverse health consequences in elderly type 2 diabetes mellitus patients; a systematic review and meta-analysis

AIM

To summarize the existing literature concerning the association between polypharmacy and adverse health consequences in elderly patients with type 2 diabetes mellitus.

METHODS

We searched four literature databases (PubMed/Medline, ScienceDirect and Web of Science) through April 2019. We included all studies that addressed the association between polypharmacy and all-cause of mortality, glycemic control, macrovacular complications, hospitalization, potentially inappropriate medicines, drug-drug interactions and fall. A statistical program OpenMeta [Analyst] was used. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with a random effects model. I² statistics was performed to assess heterogeneity.

RESULTS

Out of sixteen studies, three studies were used for meta-analysis. A statistically significant association was found between polypharmacy and all-cause mortality (OR = 1.622, 95% CI (1.606-1.637) P < 0.001), and myocardial infarction (OR = 1.962, 95% CI (1.942-1.982), P < 0.001. Non-statistically significant association with evidence of moderate heterogeneity was found between polypharmacy and stroke (OR = 1.335; 95% CI (0.532-3.346), P = 0.538, I² = 45%), and hospitalization (OR = 1.723; 95% CI (0.983-3.021), P = 0.057, I² = 57%).

CONCLUSIONS

Pooled risk estimates reveal that polypharmacy is associated with increased all-cause mortality, macrovacular complications and hospitalization using categorical definitions. These findings assert the need for interventions that optimize the balance of benefits and harms in medicines prescribing.

Pill for this and a pill for that: A cross-sectional survey of use and understanding of medication among adults with multimorbidity

OBJECTIVE

To understand the challenges managing medication use and knowledge of people living with multimorbidity.

METHODS

A cross-sectional survey of 234 adults with multimorbidity, identified using retrospective hospital discharge data. Participants were recruited from two primary health organisations in New Zealand.

RESULTS

Three quarters of participants (75%) were prescribed four or more medications, and one in four (27%) were prescribed eight or more medications. Participants reported knowing what their medications were for (88%, 95% CI 81.4-93.8) and when to take them (99%, 95% CI 97.5-99.9). However, over a fifth (22%, 95% CI 13.7-30.4) reported some problems managing multiple medications, and 40% (95% CI 30.2-50.2) reported a problem with side effects.

CONCLUSION

The results highlight the need to consider how prescribing can be adapted for people with multimorbidity and move beyond the application of multiple disease-specific guidelines.

Pharmacotherapy in Older Adults with Cardiovascular Disease: Report from an American College of Cardiology, American Geriatrics Society, and National Institute on Aging Workshop

OBJECTIVES

To identify the top priority areas for research to optimize pharmacotherapy in older adults with cardiovascular disease (CVD).

DESIGN

Consensus meeting.

SETTING

Multidisciplinary workshop supported by the National Institute on Aging, the American College of Cardiology, and the American Geriatrics Society, February 6-7, 2017.

PARTICIPANTS

Leaders in the Cardiology and Geriatrics communities, (officers in professional societies, journal editors, clinical trialists, Division chiefs), representatives from the NIA; National Heart, Lung, and Blood Institute; Food and Drug Administration; Centers for Medicare and Medicaid Services, Alliance for Academic Internal Medicine, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, pharmaceutical industry, and trainees and early career faculty with interests in geriatric cardiology.

MEASUREMENTS

Summary of workshop proceedings and recommendations.

RESULTS

To better align older adults' healthcare preferences with their care, research is needed to improve skills in patient engagement and communication. Similarly, to coordinate and meet the needs of older adults with multiple comorbidities encountering multiple healthcare providers and systems, systems and disciplines must be integrated. The lack of data from efficacy trials of CVD medications relevant to the majority of older adults creates uncertainty in determining the risks and benefits of many CVD therapies; thus, developing evidence-based guidelines for older adults with CVD is a top research priority. Polypharmacy and medication nonadherence lead to poor outcomes in older people, making research on appropriate prescribing and deprescribing to reduce polypharmacy and methods to improve adherence to beneficial therapies a priority.

CONCLUSION

The needs and circumstances of older adults with CVD differ from those that the current medical system has been designed to meet. Optimizing pharmacotherapy in older adults will require new data from traditional and pragmatic research to determine optimal CVD therapy, reduce polypharmacy, increase adherence, and meet person-centered goals. Better integration of the multiple systems and disciplines involved in the care of older adults will be essential to implement and disseminate best practices. J Am Geriatr Soc 67:371-380, 2019.

Concurrent Use of Prescription Drugs and Herbal Medicinal Products in Older Adults: A Systematic Review

Background

The use of herbal medicinal products (HMPs) is common among older adults; however, little is known about concurrent use with prescription drugs, as well as potential interactions associated with such combinations.

Objective

The aim of this systematic review was to identify and evaluate the literature on concurrent prescription and HMP use among older adults to assess prevalence, patterns, potential interactions and factors associated with this use.

Methods

Systematic searches were conducted in the MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, Web of Science and Cochrane databases from inception to May 2017 for studies reporting concurrent use of prescription medicines with HMPs in adults ≥ 65 years of age. Quality was assessed using the Joanna Briggs Institute checklists. And the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) three-stage approach to mixed method research was used to synthesise data.

Results

Twenty-two studies were included. A definition of HMPs or what was considered an HMP was frequently missing. Prevalence of concurrent use by older adults varied widely between 5.3 and 88.3%. Prescription medicines most combined with HMPs were antihypertensive drugs, β-blockers, diuretics, antihyperlipidemic agents, anticoagulants, analgesics, antihistamines, antidiabetics, antidepressants and statins. The HMPs most frequently used were Ginkgo biloba, garlic, ginseng, St John’s wort, Echinacea, saw palmetto, evening primrose oil and ginger. Potential risks of bleeding due to the use of Ginkgo biloba, garlic or ginseng with aspirin or warfarin was the most reported herb–drug interaction. Some data suggest being female, and having a lower household income and less than a high-school education were associated with concurrent use.

Conclusion

The prevalence of concurrent prescription drugs and HMP use among older adults is substantial and potential interactions have been reported. Knowledge of the extent and manner in which older adults combine prescription drugs will aid healthcare professionals in appropriately identifying and managing patients at risk. Systematic Review Registration Number: PROSPERO 2014:CRD42014009091.

Electronic supplementary material

The online version of this article (10.1007/s40266-017-0501-7) contains supplementary material, which is available to authorized users.

Prevalence and Risk of Polypharmacy Among Elderly Cancer Patients Receiving Chemotherapy in Ambulatory Oncology Setting

PURPOSE OF REVIEW

This was a single center, retrospective cross-sectional study looking into the incidence and types of drug-related problems (DRPs) detected among elderly cancer patients receiving at least three long-term medications concurrent with IV chemotherapy, and the types of intervention taken to address these DRPs. This paper serves to elucidate the prevalence and risk of polypharmacy in our geriatric oncology population in an ambulatory care setting, to raise awareness on this growing issue and to encourage more resource allocation to address this healthcare phenomenon.

RECENT FINDINGS

DRP was detected in 77.6% of elderly cancer patients receiving at least three long-term medications concurrent with IV chemotherapy, with an average incidence of three DRPs per patient. Approximately half of DRPs were related to long-term medications. Forty percent of DRPs required interventions at the prescriber level. The use of five or more medications was shown to almost double the risk of DRP occurrence (OR 1.862, P = 0.039). Out of the eight predefined categories of DRPs, underprescribing was the most common (26.7%), followed by adverse drug reaction (25.0%) and drug non-adherence (16.2%). Polypharmacy leading to DRPs is a common occurrence in elderly cancer patients receiving outpatient IV chemotherapy. There should be systematic measures in place to identify patients who are at greater risk of inappropriate polypharmacy and DRPs, and hence more frequent drug therapy optimization and monitoring. The identification of DRPs is an important step to circumvent serious drug-related harm. Future healthcare interventions directed at reducing DRPs should aim to assess the clinical and economic impact of such interventions.

Therapeutic challenges in the mature patient

With the tremendous increase in the proportion of seniors in the global population, geriatric health care has become of greater interest and concern. Increased emphasis on geriatric medicine, along with the growth in the development of age-related skin disorders, has led to particular attention for geriatric, dermatology and dermatopharmacology. An aging population has brought many therapeutic challenges that we need to recognize and overcome by applying geropharmacologic principles. The purpose of this paper is to inform dermatologists of the age-related changes in the pharmacokinetics of common dermatologic drugs, their various interactions potentially occurring in the elderly, and the principles and evidence-based strategies for detection, management, and prevention to improve medication adherence. By implementing these principles and strategies, we can ensure the best and the safest treatment to promote the desired therapeutic outcome and improved quality of life for this fragile subpopulation.

Gut Microbial Changes, Interactions, and Their Implications on Human Lifecycle: An Ageing Perspective

Gut microbiota is established during birth and evolves with age, mostly maintaining the commensal relationship with the host. A growing body of clinical evidence suggests an intricate relationship between the gut microbiota and the immune system. With ageing, the gut microbiota develops significant imbalances in the major phyla such as the anaerobic Firmicutes and Bacteroidetes as well as a diverse range of facultative organisms, resulting in impaired immune responses. Antimicrobial therapy is commonly used for the treatment of infections; however, this may also result in the loss of normal gut flora. Advanced age, antibiotic use, underlying diseases, infections, hormonal differences, circadian rhythm, and malnutrition, either alone or in combination, contribute to the problem. This nonbeneficial gastrointestinal modulation may be reversed by judicious and controlled use of antibiotics and the appropriate use of prebiotics and probiotics. In certain persistent, recurrent settings, the option of faecal microbiota transplantation can be explored. The aim of the current review is to focus on the establishment and alteration of gut microbiota, with ageing. The review also discusses the potential role of gut microbiota in regulating the immune system, together with its function in healthy and diseased state.

Number of medications or number of diseases: what influences underprescribing?

PURPOSE

An increasing number of older adults suffer from multimorbidity and receive multiple medications. Despite that, underprescribing of potentially beneficial medications is widespread in this population. Our aim was to examine influence of polypharmacy and multimorbidity on the presence of prescribing omissions (PO) in general practice attenders.

METHODS

We conducted a cross-sectional study of older adults attending general practices in Slovenia who were regularly prescribed at least one medication. Patients' data was entered into a computer application evaluating the presence of START (Screening Tool to Alert doctors to Right Treatment) criteria for PO. Demographic data, CIRS-G (Cumulative Illness Rating Scale for geriatric patients) questionnaire, number of medications, and healthcare utilization data were also collected. We defined polypharmacy as five or more concurrent medications.

RESULTS

Five hundred three patients were enrolled, 258 (56.7%) female. The average age was 74.9 and average value of CIRS-G index 1.48 (± 0.6). Patients took on average 5.6 medications and 216 (42.9%) patients had at least one PO according to START criteria. In bivariate analysis, there was a significant association between age, number of medications, polypharmacy and CIRS-G index measures, and presence of PO. In multivariate analysis, only age and number of affected CIRS-G categories significantly predicted PO (p < 0.05).

CONCLUSIONS

Older patients with more affected CIRS-G categories were at higher risk for PO. Polypharmacy was not an independent risk factor for the presence of PO. A possible reason is that in multimorbid older people, physicians and patients set individual priorities to treatment instead of treating all diseases and conditions.

Deprescribing for frail older people - Learning from the case of Mrs. Hansen

Drug treatment is often an essential part in treatment and prevention of diseases in older people, but there is much concern about inappropriate medication use. This paper aims to describe the complexity of medication safety issues and clinical judgments when optimizing prescribing in older individuals. It uses the case of Mrs. Hansen, an aged nursing home resident, to illustrate the facilitators and barriers of this process. With decreasing life expectancy, medication use should shift from cure to care, focusing on symptomatic treatment to increase the patient's well-being. In Mrs. Hansen's case, the number of (potentially) dangerous medications were reduced, and non-pharmacological alternatives were considered. There were some medicines added, as underprescribing can also be a problem in older people. Deprescribing long-standing treatment can be interpreted by the patient and family as "giving up hope". More clinical evidence and practical communication tools are needed to guide deprescribing decisions, taking medical and patient-centered priorities into account. Studies evaluating such interventions should select outcome measures that are particularly relevant for frail old individuals.

Potentially inappropriate prescribing to older patients in primary care in the Netherlands: a retrospective longitudinal study

Background

potentially inappropriate prescribing (PIP) is associated with adverse health effects in older patients. PIP comprises prescription of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs).

Objective

to estimate the prevalence of PIMs and PPOs among older patients in primary care.

Design

retrospective longitudinal study.

Setting

routinely collected data of 182,000 patients of 49 general practitioners (GPs) gathered in the GPs' database of the Academic Medical Center of Amsterdam, the Netherlands.

Subjects

in each studied year, all patients who were aged 65 years and older at 1st January.

Methods

the prevalence of patients with at least one PIM and patients with at least one PPO was measured in 8 subsequent years (2007-14) by application of the Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP)/Screening Tool to Alert doctors to Right Treatment (START) criteria. Multivariate logistic regression was used to evaluate trends in the prevalence of PIMs and PPOs over the years.

Results

on average, 4,537 patients were included per investigated year. The mean prevalence of ≥1 PIM was 34.7% (range 34.0-35.6%) and of ≥1 PPO 84.8% (range 77.4-90.6%). Examples were the prescription of salicylates without a proper indication and the absence of a therapeutically indicated vitamin D prescription. The prevalence of ≥1 PPOs showed a statistically significant decrease over the investigated years (OR 0.87, P < 0.001), whereas the prevalence of PIMs did not change significantly.

Conclusions

this study underscores the need for more attention to medication prescribing to older patients. The prevalence of PIP among older patients in primary care is substantial and the prevalence of PIMs did not decrease over time.

Clinician agreement and influence of medication-related characteristics on assessment of polypharmacy

It is not known how clinicians assess polypharmacy or the medication‐related characteristics that influence their assessment. The aim of this study was to examine the level of agreement between clinicians when assessing polypharmacy and to identify medication‐related characteristics that influence their assessment. Twenty cases of patients with varying levels of comorbidity and polypharmacy were used to examine clinician assessment of polypharmacy. Medicine‐related factors within the cases included Beers and STOPP Criteria medicines, falls‐risk medicines, drug burden index (DBI) medicines, medicines causing postural hypotension, and pharmacokinetic drug–drug interactions. Clinicians were asked to rate cases on the degree of polypharmacy, likelihood of harm, and potential for the medication list to be simplified. Inter‐rater reliability analysis, correlations, and multivariate logistic regression analyses were conducted to identify medicine factors associated with clinicians' assessment. Eighteen expert clinicians were recruited (69.2% response rate). Strong agreement was observed in clinicians' assessment of polypharmacy (intraclass correlation coefficients [ICC] = 0.94), likelihood to cause harm (ICC = 0.89), and ability to simplify medication list (ICC = 0.90). Multivariate analyses demonstrated number of medicines (P < 0.0001) and DBI scores (P = 0.047) were significantly associated with assessment of polypharmacy. Medicines associated with harm were significantly associated with the number of medicines (P = 0.01) and Beers criteria medicines (P = 0.003). Ability to simplify the medication regimen was significantly associated with number of medicines (P = 0.03) and medicines from the STOPP criteria (P = 0.018). Among clinicians, strong consensus exists with regard to assessment of polypharmacy, medication harm, and ability to simplify medications. Definitions of polypharmacy need to take into account not only the numbers of medicines but also potential for medicines to cause harm or be inappropriate, and validate them against clinical outcomes.

Drug prescription appropriateness in the elderly: an Italian study

Purpose

Correct drug prescription in the elderly is a difficult task that requires careful survey of the current pharmacological therapies. In this article, we reviewed the drug prescriptions provided to 860 persons aged 65 years or over, residing in a small city of Lombardy, Italy.

Methods

Subjects were recruited from a local nursing home, the Pavia and Vigevano Neuropsychological Center for Alzheimer’s Disease, general practitioners’ offices, and the local University of the Third Age. For each patient, the amount of potentially inappropriate prescriptions (PIPs), sedative and anticholinergic load (SL and AL, respectively), and drug–drug interactions were evaluated.

Results

Widespread polypharmacy, giving rise to 10.06% of PIPs in the whole collection of prescriptions, was observed. In particular, PIPs mainly concern drugs acting at the central nervous system level, mostly benzodiazepines and antipsychotics. Moreover, approximately one-fourth of the subjects had an elevated SL and approximately one-tenth a high AL. Drug–drug interactions were frequent (266 requiring medical attention), up to five for each single patient. Of concern was the underuse of antidementia drugs: only 20 patients received a cholinesterase inhibitor or memantine, although 183 patients were potentially suitable for this treatment.

Conclusion

These results demonstrate the need to develop novel strategies aimed at improving the quality of drug prescription.

Geriatric Care Issues: An American and an International Perspective

As the global population ages, there is an opportunity to benefit from the increased longevity of a healthy older adult population. Healthy older individuals often contribute financially to younger generations by offering financial assistance, paying more in taxes than benefits received, and providing unpaid childcare and voluntary work. Governments must address the challenges of income insecurity, access to health care, social isolation, and neglect that currently face elderly adults in many countries. A reduction in disparities in these areas can lead to better health outcomes and allow societies to benefit from longer, healthier lives of their citizens.