Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions

Examining the impact of renal dysfunction and diabetes on post-myocardial infarction mortality: insights from a comprehensive retrospective cohort study across different age groups

Aim. Chronic kidney disease (CKD) and diabetes mellitus (DM) contribute significantly to cardiovascular disease (CVD) and mortality, with prevalence increasing. The evolving demographic of myocardial infarction (MI) patients, influenced by sedentary lifestyles and advanced medical care, lacks understanding regarding the interplay of CKD, DM, age, and post-MI mortality. This study aims to address this gap by evaluating the long-term impact of CKD and DM on post-MI mortality across age groups. Methods. A retrospective cohort study utilized data from the Estonian Myocardial Infarction Registry (EMIR), Estonian Population Register (EPR), and six major hospitals in Estonia, covering AMI hospitalizations from 2012 to 2019. Statistical analyses included Cox proportional hazards regression models and Kaplan-Meier's curves. Results. Analysis of 17,085 MI patients revealed age-dependent associations between renal function and mortality. In patients <65 years, even minor decreases in renal function increased both short-term (HR 2.79, 95% CI 1.71-4.55) and long-term (HR 1.24, 95% CI 1.05-1.47) mortality. Mortality significantly increased in patients >80 years only below an estimated glomerular filtration rate (eGFR) of 44 ml/min/1.73 m2. Newly diagnosed DM patients exhibited higher mortality rates (average HR 1.53, 95% CI 1.45-1.62), while pre-DM did not significantly differ from non-DM patients across all age groups. The DM-renal failure interaction did not significantly influence mortality. Conclusions. An age-dependent association between eGFR and post-MI outcomes emphasizes the need for personalized therapeutic approaches considering age-specific eGFR thresholds and comorbidities to optimize patient management.

Deciphering the Intricate Interplay in the Framework of Antibiotic-Drug Interactions: A Narrative Review

Drug interactions are a significant and integral part of the concept of medication-related adverse events, whether referring to potential interactions or those currently observed in real-world conditions. The high global consumption of antibiotics and their pharmacokinetic and pharmacodynamic mechanisms make antibiotic-drug interactions a key element that requires continuous study due to their clinical relevance. In the present work, the current state of knowledge on antibiotic-drug interactions, which are less studied than other drug-drug interactions despite their frequent use in acute settings, has been consolidated and updated. The focus was on the interactions of the commonly used antibiotics in clinical practice, on the characteristics of the geriatric population susceptible to interactions, and on the impact of online drug interaction checkers. Additionally, strategies for optimizing the management of these interactions, including spacing out administrations, monitoring, or avoiding certain combinations, are suggested. Sustained research and careful monitoring are critical for improving antibiotic safety and efficacy, especially in susceptible populations, to enhance precision in managing antibiotic-drug interactions.

The impact of a multidisciplinary team intervention on medication prescription in nursing homes in Catalonia

Background

In response to the rising population of nursing home residents with frailty and multimorbidity, optimizing medication safety through drug utilization review and addressing medication-related problems (MRPs) is imperative. Clinical decision support systems help reduce medication errors and detect potential MRPs, as well as medication reviews performed by a multidisciplinary team, but these combined assessments are not commonly performed. The objective of this study was to evaluate the impact on medication plans of a multidisciplinary team intervention in nursing homes, by analyzing the medication plan before and after the intervention and assessing whether the recommendations given had been implemented.

Methods

A multicenter before-after study, involving five nursing homes, assessed the impact of a multidisciplinary team intervention, to estimate effectiveness related to the review of the prescribed medications. The follow-up period for each patient was 12 months or until death if prior, from July 2020 to February 2022, and involved 483 patients. The clinical pharmacologist coordinated the intervention and reviewed all the prescribed medications to make recommendations, focused on the completion of absent data, withdrawal of a drug, verification of whether a drug was adequate, the substitution of a drug, and the addition of drugs. Since the intervention was performed during the COVID-19 pandemic, optimization of psychotropic drugs and absorbent pads were limited.

Results

The intervention had an impact with recommendations given for 398 (82.4%) of the patients and which were followed by 58.5% of them. At least one drug was withdrawn in 293 (60.7%) of the patients, with a mean of 2.3 (SD 1.7). As for the total of 1,097 recommendations given, 355 (32.4%) were followed. From the intervention, antipsychotics, antidepressants, benzodiazepines, statins, and diuretics were the most frequently withdrawn.

Conclusion

The findings underscore the impact of targeted interventions to reduce inappropriate medications and enhance medication safety in nursing homes. The proposed recommendations given and followed show the importance of a multidisciplinary team, coordinated by a clinical pharmacologist, for a patient-centered approach to make medication reviews regularly, with the help of clinical decision support systems, to help reduce potential MRPs and polypharmacy.

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

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

Pharmacist interventions in Asian healthcare environments for older people: a systematic review and meta-analysis on hospitalization, mortality, and quality of life

BACKGROUND

Pharmaceutical interventions play a key role in the care of older people experiencing polypharmacy. Despite the rapid increase in the aging population in Asia, there is a lack of evidence regarding the effectiveness of pharmacist interventions on older adult's healthcare. This systematic review and meta-analysis assessed the effects of pharmacist interventions in Asian health care environments on hospitalization, mortality, and quality of life (QoL) among older people in Asia.

METHODS

A comprehensive search was conducted across 5 databases, encompassing studies published from inception through June 2023. Only studies involving pharmacist interventions for people aged 65 years or older, residing in Asian countries, were considered. Studies without evidence of pharmacist involvement or conducted outside of Asia were excluded. Data extraction was performed by two reviewers, one reviewer (I.K.) performed the initial extraction, and another reviewer (G.R.) verified the extracted data. Forest plots were generated using a random effects model to obtain risk ratios or pooled standardized mean differences (SMDs).

RESULTS

A total of 170 articles underwent thorough review, and ultimately, ten studies meeting the inclusion criteria were included in the meta-analyses. These studies encompassed diverse healthcare settings such as outpatient, inpatient, and nursing homes, with sample sizes ranging from 32 to 306 older people. Pharmacist interventions were found to significantly reduce hospitalization rates (n = 5, risk ratio = 0.57, 95% CI = 0.41-0.81) and mortality rates (n = 4, risk ratio = 0.57, 95% CI = 0.37-0.88) among older people. The analysis revealed less significant improvement in QoL in these patients than in those receiving usual care (n = 6, SMD = 0.36, P = 0.057).

CONCLUSIONS

These findings highlight the crucial role of pharmacists within healthcare teams in Asian countries. Pharmacist interventions have an impact on reducing hospitalization and mortality rates among the elderly people, underscoring the importance of optimizing patient outcomes in Asia.

The significance of G8 and other geriatric assessments in urologic cancer management: A comprehensive review

In urologic oncology, which often involves older patients, it is important to consider how to manage their care appropriately. Geriatric assessment (GA) is a method that can address the specific needs of older cancer patients. The GA encompasses various assessment domains, but these domains exhibit variations across the literature. Some of the common items include functional ability, nutrition, comorbidities, cognitive ability, psychosocial disorders, polypharmacy, social and financial support, falls/imbalance, and vision/hearing. Despite the diversity of domains, there is limited consensus on reliable measurement methods. This review discusses the role of GA in managing urologic cancer in unique scenarios, such as those necessitating temporary or permanent urinary catheters or stomas due to urinary diversion. A comprehensive GA is time and human-resource-intensive in real-world clinical practice. Hence, simpler tools such as the Geriatric-8 (G8), capable of identifying high-risk patients requiring a detailed GA, are also under investigation in various contexts. Therefore, we conducted a systematic literature review on the G8. Our findings indicate that patients with low G8 scores encounter difficulties with stoma self-care after urinary diversion and have higher risks of urinary tract infections and ileus after radical cystectomy. The utilization of G8 as a screening tool for urologic cancer patients may facilitate the delivery of appropriate and personalized treatment and care.

Medication regimen complexity and its impact on medication adherence in patients with multimorbidity at a comprehensive specialized hospital in Ethiopia

Background

Medication regimen complexity (MRC) is suspected to hinder medication adherence in patients with multiple illnesses. Despite this, the specific impact on Ethiopian patients with multimorbidity is unclear. This study assessed MRC and its impact on medication adherence in patients with multimorbidity.

Methods

A hospital-based cross-sectional study was conducted on patients with multimorbidity who had been followed at the University of Gondar Comprehensive and Specialized Hospital (UoGCSH), Ethiopia, from May to July 2021. Medication complexity was measured using the validated Medication Regimen Complexity Index (MRCI) tool, and the Adherence in Chronic Diseases Scale (ACDS) was used to measure medication adherence. Pearson's chi-square test was used to examine associations between MRCI levels and medication adherence. Ordinal logistic regression analysis was used to determine the impact of MRC and other associated variables on medication adherence. Statistical significance was determined using the adjusted odds ratio (AOR) at p-value <0.05 and its 95% confidence range.

Results

Out of 422 eligible patients, 416 (98.6%) were included in the study. The majority of participants (57.2%) were classified as having a high MRCI score with a mean (±SD) score of 9.7 (±3.4). Nearly half of the patients (49.3%) had low medication adherence. Patients with medium (AOR = 0.43, 95% CI: 0.04, 0.72) and higher (AOR = 0.31, 95% CI: 0.07, 0.79) MRCI levels had lower odds of medication adherence. In addition, monthly income (AOR = 4.59, 95% CI: 2.14, 9.83), follow-up durations (AOR = 2.31, 95% CI: 1.09, 4.86), number of medications (AOR = 0.63, 95% CI: 0.41, 0.97), and Charlson comorbidity index (CCI) (AOR = 0.36, 95% CI: 0.16, 0.83) were significantly associated with medication adherence.

Conclusion

Medication regimen complexity in patients with multimorbidity was found to be high and negatively impacted the levels of medication adherence. Healthcare providers and other stakeholders should seek interventions aimed at simplifying drug regimen complexity and improving adherence.

Managing polypharmacy through medication review tools - pros and cons

Inappropriate polypharmacy is a common occurrence in elderly patients, resulting in increased adverse drug reactions, nonadherence, and increased healthcare costs. Medication review and deprescribing are the primary strategies described in the literature for dealing with problematic polypharmacy. To effectively carry out the medication review, various tools have been developed. These tools can support medication review in a variety of ways. Some tools include a list of medications requiring detailed attention, while others guide medical professionals with principles and algorithms for reviewing and prescribing medicines. A third category of tools focuses on tracking and identifying symptoms that may be due to drug-related problems.

Use of drugs with pharmacogenomics (PGx)-based dosing guidelines in a Danish cohort of persons with chronic kidney disease, both on dialysis and not on dialysis: Perspectives for prescribing optimization

AIM

The objective of this registry study is to assess the utilization of pharmacogenomic (PGx) drugs among patients with chronic kidney disease (CKD).

METHODS

This study was a retrospective study of patients affiliated with the Department of Nephrology, Aalborg University Hospital, Denmark in 2021. Patients diagnosed with CKD were divided into CKD without dialysis and CKD with dialysis. PGx prescription drugs were retrieved from the Patient Administration System. Actionable dosing guidelines (AG) for specific drug-gene pairs for CYP2D6, CYP2C9, CYP2C19 and SLCO1B1 were retrieved from the PharmGKB homepage.

RESULTS

Out of 1241 individuals, 25.5% were on dialysis. The median number of medications for each patient was 9 within the non-dialysis group and 16 within the dialysis group. Thirty-one distinct PGx drugs were prescribed. Altogether, 76.0% (943 individuals) were prescribed at least one PGx drug and the prevalence of prescriptions of PGx drugs was higher in the dialysis group compared to the non-dialysis group. The most frequently prescribed drugs with AG were metoprolol, pantoprazole, atorvastatin, simvastatin and warfarin.

CONCLUSION

This study demonstrated that a substantial proportion of patients with CKD are exposed to drugs or drug combinations for which there exists AG related to PGx of CYP2D6, CYP2C19, CYP2C9 and SLCO1B1.

"Inspiratory muscle weakness in acutely hospitalized patients 75 years and over": a secondary analysis of a randomized controlled trial on the effectiveness of multicomponent exercise and inspiratory muscle training

PURPOSE

The impact of hospitalization for acute illness on inspiratory muscle strength in oldest-old patients is largely unknown, as are the potential benefits of exercise and inspiratory muscle training (IMT) during in-hospital stay.

DESIGN AND METHODS

This was a sub-study of a randomized clinical trial that evaluated the efficiency of a multicomponent exercise program in preventing hospitalization-associated disability. Patients were randomized into control (CG) and intervention (IG) groups. The intervention included two daily sessions of supervised walking, squat, balance, and IMT. Baseline and discharge maximal inspiratory pressure (MIP) and inspiratory muscle weakness (IMW) were determined. The effect of the intervention on inspiratory muscle strength was assessed by analyzing (1) the differences between groups in baseline and discharge MIP and IMW, (2) the association, patient by patient, between baseline and discharge MIP, and the improvement index (MIP discharge/baseline) in patients with or without IMW.

RESULTS

In total, 174 patients were assessed (mean age of 87), 57 in CG and 117 in IG. Baseline MIP was lower than predicted in both sexes (women 29.7 vs 44.3; men 36.7 vs 62.5 cmH2O, P < 0.001, baseline vs predicted, respectively). More than 65% of patients showed IMW at admission. In women in IG, the mean MIP was higher at discharge than at admission (P = 0.003) and was the only variable that reached expected reference levels at discharge (Measured MIP 39.2 vs predicted MIP 45 cmH2O, P = 0.883). Patients with IMW on admission showed a statistically significant improvement in MIP after the intervention.

CONCLUSION

IMW is very prevalent in oldest-old hospitalized with acute illness. Patients might benefit from a multicomponent exercise program including IMT, even during short-stay hospitalization.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NTC03604640. May 3, 2018.

Drug therapy problems among hospitalized patients with cardiovascular disease

BACKGROUND

Optimal utilization of cardiovascular drugs is crucial in reducing morbidity and mortality associated with cardiovascular diseases. However, the effectiveness of these drugs can be compromised by drug therapy problems. Hospitalized patients with cardiovascular diseases, particularly those with multiple comorbidities, polypharmacy, and advanced age, are more susceptible to experiencing drug therapy problems. However, little is known about drug therapy problems and their contributing factors among patients with cardiovascular disease in our setting. Therefore, our study aimed to investigate drug therapy problems and their contributing factors in patients with cardiovascular diseases.

METHOD

A prospective observational study was conducted among hospitalized patients with cardiovascular disease at Ayder Comprehensive Specialized Hospital in the Tigray region of Northern Ethiopia from December 2020 to May 2021. We collected the data through patient interviews and review of patients' medical records. We employed Cipolle's method to identify and categorize drug therapy problems and sought consensus from a panel of experts through review. Data analysis was performed using the Statistical Software Package SPSS version 22. Binary logistic regression analysis was performed to determine the contributing factors of drug therapy problems in patients with cardiovascular disease. Statistical significance was set at p < 0.05.

RESULTS

The study included a total of 222 patients, of whom 117 (52.7%) experienced one or more drug-related problems. We identified 177 drug therapy problems equating to 1.4 ± 0.7 drug therapy problems per patients. The most frequently identified DTP was the need for additional drug therapy (32.4%), followed by ineffective drug therapy (14%), and unnecessary drug therapy (13.1%). The predicting factors for drug therapy problems were old age (AOR: 3.97, 95%CI: 1.68-9.36) and number of medications ≥ 5 (AOR: 2.68, 95%CI: 1.47-5.11).

CONCLUSION

More than half of the patients experienced drug therapy problems in our study. Old age and number of medications were the predicting factors of drug therapy problems. Therefore, greater attention and focus should be given to patients who are at risk of developing drug therapy problems.

Inappropriate polypharmacy management versus deprescribing: A review on their relationship

Medication burden and polypharmacy are highly prevalent among patients with multimorbidity. There have been multiple initiatives to overcome polypharmacy and medication burden in patients with multimorbidity. These initiatives have evolved over time as effective in reducing the negative health consequences of polypharmacy. In recent years, the concept and practice of deprescribing has emerged and gained popularity as an efficient comprehensive approach to manage polypharmacy and ultimately improve health outcomes. Clinicians and researchers with interest in deprescribing view it as a novel and unique strategy that should be a part of effective prescribing process. However, other traditional polypharmacy management strategies such as drug review and medication therapy management still coexist. It is intriguing if deprescribing is considered as a type of these strategies or not. This narrative mini-review explored published literature in an effort to ascertain the differences and similarities between deprescribing and other prominent polypharmacy management interventions. It is clear that there is an overlap between deprescribing and inappropriate polypharmacy management. This is represented by focusing on multimorbid older adults, using similar explicit and implicit tools and having drug review as the core principle of both approaches. This overlap has probably made deprescribing considered as one of polypharmacy management approaches.

Prevalence of and Risk Factors for Drug-Related Readmissions in Older Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Older adults are at an increased risk of drug-related problems, especially following discharge from hospital. Drug-related readmissions place a large burden on the patient and the healthcare system. However, previous studies report inconsistent results on the prevalence and associated risk factors for drug-related hospital readmissions in older adults.

OBJECTIVES

We aimed to assess the prevalence of drug-related readmissions in older adults aged 65 years and older and investigate the drug classes, preventability and risk factors most associated with these readmissions.

METHODS

A systematic review and meta-analysis were undertaken to answer our objectives. A search of four databases (MEDLINE, Embase, CINAHL and Scopus) was conducted. Three authors independently performed title and abstract screening, full-text screening and data extraction of all included studies. A meta-analysis was conducted to calculate the pooled prevalence of drug-related readmissions across all studies, and a subgroup analysis was performed to explore heterogeneity among studies reporting on adverse drug reaction-related readmissions.

RESULTS

A total of 1978 studies were identified in the initial search, of which four studies were included in the final synthesis. Three studies focused on readmissions due to adverse drug reactions and one study focused on readmissions due to drug-related problems. A pooled prevalence of 9% (95% confidence interval 2-18) was found for drug-related readmissions across all studies, and a pooled prevalence of 6% (95% confidence interval 4-10) was found for adverse drug reaction-related readmissions. Three studies explored the preventability of readmissions and 15.4-22.2% of cases were deemed preventable. The drug classes most associated with adverse drug reaction readmissions included anticoagulants, antibiotics, psychotropics and chemotherapy agents. Polypharmacy (the use of five or more medications) and several comorbidities such as cancer, liver disease, ischaemic heart disease and peptic ulcer disease were identified as risk factors for drug-related readmissions.

CONCLUSIONS

Almost one in ten older adults discharged from hospital experienced a drug-related hospital readmission, with one fifth of these deemed preventable. Several comorbidities and the use of polypharmacy and high-risk drugs were identified as prominent risk factors for readmission. Further research is needed to explore possible causes of drug-related readmissions in older adults for a more guided approach to the development of effective medication management interventions.

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

Background

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

Methods

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

Results

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

Conclusion

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

Polypharmacy in the Cardiovascular Geriatric Critical Care Population: Improving Outcomes

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

Optimizing polypharmacy management in the elderly: a comprehensive European benchmarking survey and the development of an innovative online benchmarking application

Background: Polypharmacy, defined as the simultaneous use of multiple medications by a patient, is a worldwide problem of rising prevalence. Paving the way for drug interactions, adverse drug reactions and non-adherence, it leads to negative health outcomes, increased use of healthcare services and rising costs. Since it is closely related to multimorbidity, it peaks in older adults. So far, not many polypharmacy management programs in the elderly have been introduced in practice. However, due to the rapid ageing of European societies, there is an urgent need to implement them more widely. Objective: The aim of this study was to benchmark polypharmacy management programs in the elderly available in Europe and creating a dedicated benchmarking application. Methods: It was a cross-sectional study based on an online survey targeting healthcare professionals and other stakeholders across European countries. Data collected in the survey were reused to design an online benchmarking application. Results: As many as 911 respondents from all but two EU countries took part in this study. Out of the survey participants, 496 (54.4%) reported availability of various activities or formal programs targeting polypharmacy in the elderly that were known to them. These programs had multiple goals, of which improved patient safety was indicated as the most common objective (65.1% of the cases). The most typical settings for such programs was primary care (49.4%), with pharmacists and primary care doctors being indicated most often as those providing the programs (61.7% and 35.5% of cases, respectively). Vast majority of programs applied diverse forms of drug reviews. The identified programs were assessed against four predefined dimensions of effectiveness, applicability, scalability and cost-effectiveness. The lowest scores were obtained within the last of these categories, due to unavailability of relevant data. Based on the survey results, a benchmarking application was constructed. It allows for comparing an individual polypharmacy management program targeting the elderly against the other ones, and particularly, against the national and European context. Conclusion: By providing strong evidence, the findings of this study, coupled with the benchmarking application, can prove valuable in aiding clinicians and policymakers in the implementation and expansion of polypharmacy management programs for the elderly.

Medication Adherence in Patients with Hematologic Malignancies Who Are Hematopoietic Stem Cell Transplantation Survivors: A Qualitative Study

Medication adherence is critical for optimal health outcomes in patients with hematologic malignancies who have undergone allogeneic hematopoietic stem cell transplants (HSCT). However, this population struggles with medication nonadherence. Research that comprehensively describes the complex patient- and medication-related factors which impact medication adherence in this population is lacking. Hence, we used semistructured qualitative interviews to explore the diverse and complex factors contributing to medication adherence in HSCT recipients. We conducted 30 in-depth interviews with patients who were more than 180 days post-allogeneic HSCT at the Dana-Farber Cancer Institute. The interviews explored the physical, social, psychological, and sociodemographic factors that facilitate or discourage adherence to the post-transplantation medication regimen. Interviews were audio-recorded, transcribed, and coded using NVivo software. Two themes emerged that characterized the barriers patients face with their medication regimen. Patients reported factors outside of their control, such as managing multiple pharmacies, health insurance difficulties, and dosage timing, as significant barriers to medication adherence. Patients also reported barriers within their control, such as familial responsibilities. Important facilitators for medication adherence included caregiver and clinician support, previous experience managing a medication regimen, and tools that aid pill organization and timing. Furthermore, patients reported that although medication side effects and quantity of pills did not directly impact medication adherence, it increased their psychological distress. Facilitators and barriers to medication adherence can be physical, psychological, organizational, and social. There are many aspects of medication regimens that significantly increase patient distress. Hence, supportive interventions to improve medication adherence in patients undergoing HSCT may need to incorporate strategies to manage medication side effects and skills to improve psychological well-being and social support.

Utilizing Social Determinants of Health Model to Understand Barriers to Medication Adherence in Patients with Ischemic Stroke: A Systematic Review

Introduction

Ischemic strokes and their recurrence create an immense disease burden globally. Therefore, preventing recurrent strokes by promoting medication adherence is crucial to reduce morbidity and mortality. In addition, understanding the barriers to medication adherence related to the social determinants of health (SDoH) could promote equity among persons with ischemic stroke.

Objective

To explore the barriers to medication adherence among patients with ischemic stroke through the SDoH.

Methods

This systematic review included studies published between January 2018 and December 2022 identified through PubMed, MEDLINE, Web of Science, and CINAHL Plus Full Text. The descriptions of the studies were systematically summarized and discussed based on the SDoH from the US Healthy People 2030 initiative.

Results

Eight studies met the inclusion criteria and were included in this review. The most common barrier to adherence was inappropriate medication beliefs, medication side effects, and patient-physician relationship, which relate to the dimensions of healthcare access and quality. Health literacy and health perception, dependent on education access and quality, frequently influenced adherence. Other social determinants, such as financial strain and social and community context, were found to alter adherence behaviors. No study addressed the neighborhood and built environment domain. We found that cognitive impairment is another factor that impacts adherence outcomes among stroke patients.

Conclusion

Multifaceted approaches are needed to address the SDoH to improve medication adherence among patients with ischemic stroke. This review emphasized strategies, including patient education, provider-patient communication, social support, health literacy, technology, and policy advocacy to enhance adherence.

The effects of pharmaceutical interventions on potentially inappropriate medications in older patients: a systematic review and meta-analysis

Introduction

Potentially inappropriate medications (PIMs) is a particular concern in older patients and is associated with negative health outcomes. As various interventions have been developed to manage it, we performed a systematic review and meta-analysis to evaluate the effect of pharmaceutical interventions on outcomes of PIMs in older patients.

Methods

Meta-analysis of eligible randomized controlled trials (RCTs) was conducted to report the outcomes of pharmaceutical interventions in older patients searching from the databases of Cochrane Library, PubMed, Embase, Web of Science, Clinicaltrials.gov, SinoMed and Chinese Clinical Trial Registry (ChiCTR). The PRISMA guidelines were followed and the protocol was registered in PROSPERO (CRD42019134754). Cochrane bias risk assessment tool and the modified Jadad scale were used to assess the risk bias. RevMan software was used for data processing, analysis and graphical plotting.

Results

Sixty-five thousand, nine hundred seventy-one patients in 14 RCTs were included. Of the primary outcomes, pharmaceutical interventions could significantly reduce the incidence of PIMs in older patients (OR = 0.51, 95% CI: 0.42, 0.62; p < 0.001), and the number of PIMs per person (MD = -0.41, 95%CI: -0.51, -0.31; p < 0.001), accompanying by a low heterogeneity. Subgroup analysis showed that the application of computer-based clinical decision support for pharmacological interventions could remarkably decrease the incidence of PIMs and two assessment tools were more effective. Of the secondary outcomes, the meta-analysis showed that pharmacological interventions could reduce the number of drugs used per person (MD = -0.94, 95%CI: -1.51, -0.36; p = 0.001) and 30-day readmission rate (OR = 0.58, 95%CI: 0.36, 0.92; p = 0.02), accompanying by a low heterogeneity. However, the pharmaceutical interventions demonstrated no significant improvement on all-cause mortality and the number of falls.

Conclusion

Our findings supported the efficacy of pharmaceutical interventions to optimize the use and management of drugs in older patients.

Systematic review registration

https://clinicaltrials.gov/, CRD42019134754.

Complex implementation mechanisms in primary care: do physicians' beliefs about the effectiveness of innovation play a mediating role? Applying a realist inquiry and structural equation modeling approach in a formative evaluation study

BACKGROUND

The adoption of digital health technologies can improve the quality of care for polypharmacy patients, if the underlying complex implementation mechanisms are better understood. Context effects play a critical role in relation to implementation mechanisms. In primary care research, evidence on the effects of context in the adoption of digital innovation for polypharmacy management is lacking.

STUDY AIM

This study aims to identify contextual factors relevant to physician behavior and how they might mediate the adoption process.

METHODS

The physicians who participated in this formative evaluation study (n = 218) were part of the intervention group in a cluster-randomized controlled trial (AdAM). The intervention group implemented a digital innovation for clinical decision making in polypharmacy. A three-step methodological approach was used: (1) a realist inquiry approach, which involves the description of a context-mechanism-outcome configuration for the primary care setting; (2) a belief elicitation approach, which involves qualitative content analysis and the development of a quantitative latent contextualized scale; and (3) a mediation analysis using structural equation modeling (SEM) based on quantitative survey data from physicians to assess the mediating role of the contextualized scale (n = 179).

RESULTS

The key dimensions of a (1) context-mechanism-outcome model were mapped and refined. A (2) latent construct of the physicians' innovation beliefs related to the effectiveness of polypharmacy management practices was identified. Innovation beliefs play a (3) mediating role between the organizational readiness to implement change (p < 0.01) and the desired behavioral intent of physicians to adopt digital innovation (p < 0.01; R² = 0.645). Our contextualized model estimated significant mediation, with a relative size of 38% for the mediation effect. Overall, the model demonstrated good fit indices (CFI = 0.985, RMSEA = 0.034).

CONCLUSION

Physician adoption is directly affected by the readiness of primary care organizations for the implementation of change. In addition, the mediation analysis revealed that this relationship is indirectly influenced by primary care physicians' beliefs regarding the effectiveness of digital innovation. Both individual physician beliefs and practice organizational capacity could be equally prioritized in developing implementation strategies. The methodological approach used is suitable for the evaluation of complex implementation mechanisms. It has been proven to be an advantageous approach for formative evaluation.

TRIAL REGISTRATION

NCT03430336 . First registration: 12/02/2018.

CLINICALTRIALS

gov.

A Critical View over the Newest Antidiabetic Molecules in Light of Efficacy-A Systematic Review and Meta-Analysis

The increase in life expectancy without a decrease in the years lived without disability leads to the rise of the population aged over 65 years prone to polypharmacy. The novel antidiabetic drugs can improve this global therapeutic and health problem in patients with diabetes mellitus (DM). We aimed to establish the efficacy (A1c hemoglobin reduction) and safety of the newest antidiabetic drugs (considered so due to their novelty in medical practice use), specifically DPP-4i, SGLT-2i, GLP-1 Ra, and tirzepatide. The present meta-analysis followed the protocol registered at Prospero with the CRD42022330442 registration number. The reduction in HbA1c in the DPP4-i class for tenegliptin was 95% CI -0.54 [-1.1, 0.01], p = 0.06; in the SGLT2-iclass for ipragliflozin 95% CI -0.2 [-0.87, 0.47], p = 0.55; and for tofogliflozin 95% CI 3.13 [-12.02, 18.28], p = 0.69, while for tirzepatide it was 0.15, 95% CI [-0.50, 0.80] (p = 0.65). The guidelines for treatment in type 2 DM are provided from cardiovascular outcome trials that report mainly major adverse cardiovascular events and data about efficacy. The newest antidiabetic non-insulinic drugs are reported to be efficient in lowering HbA1c, but this effect depends between classes, molecules, or patients' age. The newest antidiabetic drugs are proven to be efficient molecules in terms of HbA1c decrease, weight reduction, and safety, but more studies are needed in order to characterize exactly their efficacy and safety profiles.

Epidemiology and association with outcomes of polypharmacy in patients undergoing surgery: retrospective, population-based cohort study

BACKGROUND

The aim of this study was to determine the prevalence of preoperative polypharmacy and the incidence of postoperative polypharmacy/hyper-polypharmacy in surgical patients and their association with adverse outcomes.

METHODS

This was a retrospective, population-based cohort study among patients older than or equal to 18 years undergoing surgery at a university hospital between 2005 and 2018. Patients were categorized based on the number of medications: non-polypharmacy (fewer than 5); polypharmacy (5-9); and hyper-polypharmacy (greater than or equal to 10). The 30-day mortality, prolonged hospitalization (greater than or equal to 10 days), and incidence of readmission were compared between medication-use categories.

RESULTS

Among 55 997 patients, the prevalence of preoperative polypharmacy was 32.3 per cent (95 per cent c.i. 33.5 to 34.3) and the prevalence of hyper-polypharmacy was 25.5 per cent (95 per cent c.i. 25.2 to 25.9). Thirty-day mortality was higher for patients exposed to preoperative hyper-polypharmacy (2.3 per cent) and preoperative polypharmacy (0.8 per cent) compared with those exposed to non-polypharmacy (0.6 per cent) (P < 0.001). The hazards ratio (HR) of long-term mortality was higher for patients exposed to hyper-polypharmacy (HR 1.32 (95 per cent c.i. 1.25 to 1.40)) and polypharmacy (HR 1.07 (95 per cent c.i. 1.01 to 1.14)) after adjustment for patient and procedural variables. The incidence of longer hospitalization (greater than or equal to 10 days) was higher for hyper-polypharmacy (11.3 per cent) and polypharmacy (6.3 per cent) compared with non-polypharmacy (4.1 per cent) (P < 0.001). The 30-day incidence of readmission was higher for patients exposed to hyper-polypharmacy (10.2 per cent) compared with polypharmacy (6.1 per cent) and non-polypharmacy (4.8 per cent) (P < 0.001). Among patients not exposed to polypharmacy, the incidence of new postoperative polypharmacy/hyper-polypharmacy was 33.4 per cent (95 per cent c.i. 32.8 to 34.1), and, for patients exposed to preoperative polypharmacy, the incidence of postoperative hyper-polypharmacy was 16.3 per cent (95 per cent c.i. 16.0 to 16.7).

CONCLUSION

Preoperative polypharmacy and new postoperative polypharmacy/hyper-polypharmacy are common and associated with adverse outcomes. This highlights the need for increased emphasis on optimizing medication usage throughout the perioperative interval.

REGISTRATION NUMBER

NCT04805151 (http://clinicaltrials.gov).

Association of polypharmacy and potential drug-drug interactions with adverse treatment outcomes in older adults with advanced cancer

BACKGROUND

Polypharmacy is common in older adults who are starting cancer treatment and is associated with an increased risk of potentially inappropriate medications (PIMs) and potential drug-drug interactions (PDIs). The authors evaluated the association of medication measures with adverse outcomes in older adults with advanced cancer who were receiving systemic therapy.

METHODS

This secondary analysis from GAP 70+ Trial (ClinicalTrials.gov identifier NCT02054741; principal investigator, Supriya G. Mohile) enrolled patients aged 70 years and older with advanced cancer who planned to start a new treatment regimen (n = 718). Polypharmacy was assessed before the initiation of treatment and was defined as the concurrent use of eight or more medications. PIMs were categorized using 2019 Beers Criteria and the Screening Tool of Older Persons' Prescriptions. PDIs were evaluated using Lexi-Interact Online. Study outcomes were assessed within 3 months of treatment and included: (1) the number of grade ≥2 and ≥3 toxicities according to the National Cancer Institute Common Toxicity Criteria, (2) treatment-related unplanned hospitalization, and (3) early treatment discontinuation. Multivariable regression models examined the association of medication measures with outcomes.

RESULTS

The mean patient age was 77 years, and 57% had lung or gastrointestinal cancers. The median number of medications was five (range, 0-24 medications), 28% of patients received eight or more medications, 67% received one or more PIM, and 25% had one or more major PDI. The mean number of grade ≥2 toxicities in patients with polypharmacy was 9.8 versus 7.7 in those without polypharmacy (adjusted β = 1.87; standard error, 0.71; p <.01). The mean number of grade ≥3 toxicities in patients with polypharmacy was 2.9 versus 2.2 in patients without polypharmacy (adjusted β = 0.59; standard error, 0.29; p = .04). Patients with who had one or more major PDI had 59% higher odds of early treatment discontinuation (odds ratio, 1.59; 95% confidence interval, 1.03-2.46; p = .03).

CONCLUSIONS

In a cohort of older adults with advanced cancer, polypharmacy and PDIs were associated with an increased risk of adverse treatment outcomes. Providing meaningful screening and interventional tools to optimize medication use may improve treatment-related outcomes in these patients.

Patients' Perceived Importance of Medication and Adherence in Polypharmacy, a Quantitative, Cross-Sectional Study Using a Questionnaire Administered in Three Doctors' Private Practices in France

BACKGROUND

Among the determinants of nonadherence, polypharmacy (common in people with multiple pathologies and especially in elderly patients), plays a major role.

OBJECTIVE

In patients who are subject to polypharmacy involving different classes of medications, the first aim is to assess the impact of medication importance given by patients on (i) medication adherence and (ii) the respective effect of intentionality and habit in medication importance and medication adherence. The second objective is to compare the importance given to medication and adherence in the different therapeutic classes.

PATIENTS AND METHODS

Patients taking 5-10 different medications for at least 1 month were included in a cross-sectional survey in three private practices in one region in France.

RESULTS

This study included 130 patients (59.2 % female) with 851 medications in total. The mean ± standard deviation (SD) age was 70.5 ± 12.2 years. The mean ± SD of medications taken was 6.9 ± 1.7. Treatment adherence had a strong positive correlation with the patient-perceived medication importance (p < 0.001). Counter-intuitively, taking a large number of medications (≥7) was associated with being fully adherent (p = 0.02). A high intentional nonadherence score was negatively associated with high medication importance (p = 0.003). Furthermore, patient-perceived medication importance was positively associated with taking treatment by habit (p = 0.03). Overall nonadherence more strongly correlated with unintentional nonadherence (p < 0.001) than with intentional nonadherence (p = 0.02). Compared to the antihypertensive class, a decrease in adherence by medication was observed in psychoanaleptics (p < 0.0001) and drugs used in diabetes class (p = 0.002), and a decrease in importance in lipid-modifying agents class (p = 0.001) and psychoanaleptics (p < 0.0001).

CONCLUSION

The perception of the importance of a medicine is associated with the place of intentionality and habit in patient adherence. Therefore, explaining the importance of a medicine should become an important part of patient education.

Half a Century of Fragmented Research on Deviations from Advised Therapies: Is This a Good Time to Call for Multidisciplinary Medication Adherence Research Centres of Excellence?

Medication adherence is a key precondition of the effectiveness of evidence-based therapies. However, in real-life settings, non-adherence to medication is still very common. This leads to profound health and economic consequences at both individual and public health levels. The problem of non-adherence has been extensively studied in the last 50 years. Unfortunately, with more than 130,000 scientific papers published on that subject so far, we are still far from finding an ultimate solution. This is, at least partly, due to fragmented and poor-quality research that has been conducted in this field sometimes. To overcome this deadlock, there is a need to stimulate the adoption of best practices in medication adherence-related research in a systematic way. Therefore, herein we propose the establishment of dedicated medication adherence research Centres of Excellence (CoEs). These Centres could not only conduct research but could also create a profound societal impact, directly serving the needs of patients, healthcare providers, systems and economies. Additionally, they could play a role as local advocates for good practices and education. In this paper, we propose some practical steps that might be taken in order to establish such CoEs. We describe two success stories, i.e., Dutch and Polish Medication Adherence Research CoEs. The COST Action "European Network to Advance Best practices & technoLogy on medication adherencE" (ENABLE) aims to develop a detailed definition of the Medication Adherence Research CoE in the form of a list of minimal requirements regarding their objectives, structure and activities. We hope that it will help to create a critical mass and catalyse the setup of regional and national Medication Adherence Research CoEs in the near future. This, in turn, may not only increase the quality of the research but also raise the awareness of non-adherence and promote the adoption of the best medication adherence-enhancing interventions.

Association of polypharmacy with incidence of CKD: a retrospective cohort study

BACKGROUND

Polypharmacy is common in patients with chronic kidney disease (CKD) and is associated with a decline in kidney function. However, its impact on patients without CKD has not been adequately elucidated. Therefore, we aimed to investigate the association between polypharmacy and the incidence of CKD.

METHODS

We conducted retrospective cohort study using 1221 participants who were enrolled in the Fukushima Cohort Study with one or more risk factors of CKD, an estimated glomerular filtration rate (eGFR) of ≥ 60 mL/min/1.73 m², and without proteinuria. Participants were categorized into three groups based on the number of medications: non-polypharmacy, 0-4 medications; polypharmacy, 5-9 medications; and hyper-polypharmacy, ≥ 10 medications.

RESULTS

The median age was 62 years, 49% were men, the median eGFR was 75.4 ml/min/1.73 m², and the median number of medications was 5. Polypharmacy and hyper-polypharmacy were noted in 506 (41%) and 250 (20%) participants, respectively. During follow-up, 288 participants developed CKD and 67 cardiovascular events were observed. Compared to the non-polypharmacy group, the hyper-polypharmacy group had a higher risk of CKD and cardiovascular events. The adjusted hazard ratios were 1.41 (95% CI1.01-1.99) and 2.24 (95% CI1.05-4.78) for the incidence of CKD and cardiovascular events, respectively. Sensitivity analyses yielded similar findings for the restricted cubic spline function models.

CONCLUSIONS

Hyper-polypharmacy is associated with a higher risk of CKD and cardiovascular events.

Patterns of polyphenol intake and risk of depressive symptomatology in a population-based cohort of older adults

BACKGROUND & AIMS

Current evidence suggests that some isolated polyphenols (PP) may exert promising effects for the risk of depression in young adults, however studies among older adults remain limited. The aim of the current study was to examine the prospective association between patterns of PP intake and the risk of depressive symptomatology (DS) in older adults.

METHODS

The study sample was based on the Three-City (3C) Bordeaux cohort of adults aged 65 years and over and without DS at the time of recruitment. The intakes of PP, summarised into 21 PP classes, were determined using a 24-h recall combined with the Phenol-Explorer database. In addition, the patterns of PP intake were identified by a Principal Component Analysis (PCA). DS was evaluated using the Center for Epidemiologic Studies Depression Scale (CES-D) over a period of 15 years with a reassessment every 2-3 years. The incident DS was reported for CES-D score ≥16 and/or the use of antidepressant treatment. The association between the patterns of PP intake at baseline and the risk of DS was computed using multivariate random-effect logistic regression models.

RESULTS

Among the 1074 participants (mean age 75.7 y, SD 4.8 y), 423 (39.4%) developed a DS during the follow-up. Distinct patterns of PP intake were identified, explaining up to 50% of the variance. The two first patterns, mainly driven by stilbenes and dihydroflavonols and by hydroxyicnnamic acid and alkylmethoxyphenols respectively, were not associated with the odds of DS. Furthermore, a higher score on the third pattern, mainly driven by monomeric flavanols and theaflavins, was associated with a significant 27% lower risk of DS over time (Odd Ratio = 0.73, 95% Confidence Interval [0.55; 0.97]).

CONCLUSION

This prospective study suggested that a pattern high in monomeric flavanols and theaflavins intakes, mainly provided by tea, was associated with a reduced risk of DS in older adults. These results provide promising evidence on combined PP intakes that would require further confirmation in other samples.

Factors associated with polypharmacy and the high risk of medication-related problems among older community-dwelling adults in European countries: a longitudinal study

Background

Polypharmacy can be defined as using five or more medications simultaneously. “Medication-related problems”, an extension of polypharmacy, includes inappropriate prescribing, poor adherence, overdosage, underdosage, inappropriate drug selection, inadequate monitoring, adverse drug effects, and drug interactions. Polypharmacy and the high risk of medication-related problems among older people are associated with adverse health consequences due to drug-drug interactions, drug-disease interactions, and adverse drug effects. This study aims to assess the factors associated with polypharmacy and the high risk of medication-related problems among community-dwelling older people in the Netherlands, Greece, Croatia, Spain, United Kingdom.

Method

This longitudinal study used baseline and follow-up data from 1791 participants of the Urban Health Center European project. Polypharmacy and the risk of medication-related problems were evaluated at baseline and follow-up using the Medication Risk Questionnaire. We studied factors in the domains (a) sociodemographic characteristics, (b) lifestyle and nutrition, and (c) health and health care use. Hierarchical logistic regression analyses were used to examine the factors associated with polypharmacy and the high risk of medication-related problems.

Results

Mean age was 79.6 years (SD ± 5.6 years); 60.8% were women; 45.2% had polypharmacy, and 41.8% had a high risk of medication-related problems. Women participants had lower odds of polypharmacy (OR = 0.55;95%CI:0.42–0.72) and a high risk of medication-related problems (OR = 0.50; 95%CI:0.39–0.65). Participants with a migration background (OR = 1.67;95%CI:1.08–2.59), overweight (OR = 1.37; 95%CI:1.04–1.79) and obesity (OR = 1.78;95%CI:1.26–2.51) compared to ‘normal weight’, with lower physical HRQoL (OR = 0.96, 95%CI:0.95–0.98), multi-morbidity (OR = 3.73, 95%CI:2.18–6.37), frailty (OR = 1.69, 95%CI:1.24–2.30), visited outpatient services (OR = 1.77, 95%CI: 1.09–2.88) had higher odds of polypharmacy. The associations with the high risk of medication-related problems were similar.

Conclusions

Multiple factors in demography, lifestyle, nutrition, and health care use are associated with polypharmacy and the high risk of medication-related problems. Polypharmacy is a single element that may reflect the number of medications taken. The broader content of medication-related problems should be considered to assess the context of medication use among older people comprehensively. These provide starting points to improve interventions to reduce polypharmacy and high risk of medication-related problems. In the meantime, health professionals can apply these insights to identify subgroups of patients at a high risk of polypharmacy and medication-related problems.

Trial registration

The intervention of the UHCE project was registered in the ISRCTN registry as ISRCTN52788952. The date of registration is 13/03/2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03536-z.

Safety of Mexidol® (ethylmethylhydroxypyridine succinate) in adult patients of different age groups

To reduce the risk of developing adverse events (AEs) and increase the adherence of elderly patients to treatment, it is recommended to limit maximally the total number of prescribed drugs (DR), using one drug for the treatment of two or more pathologies if possible. The drugs that meet the criteria for use in elderly patients and / or patients with comorbidity include the original Russian drug Mexidol® (ethylmethylhydroxypyridine succinate), which has a multimodal mechanism of action and has multiple pharmacological effects. In order to study the safety of Mexidol in comparison with placebo in different age groups of patients with chronic cerebral ischemia, a post hoc analysis of the international multicenter, randomized, double-blind, placebo-controlled MEMO study with an adaptive design was carried out, which assessed the efficacy and safety of sequential therapy with Mexidol®, a solution for intravenous and intramuscular injection, 50 mg/ml (NPK PHARMASOFT, Russia) and Mexidol® FORTE 250 film-coated tablets, 250 mg (NPK PHARMASOFT, Russia) in patients with chronic cerebral ischemia. The study involved 318 patients aged from 40 to 90 years.

Comparable safety and tolerability of Mexidol was demonstrated in middle-aged and elderly people with chronic cerebral ischemia, including patients over 75 years of age. 

Recent Updates on Risk and Management Plans Associated with Polypharmacy in Older Population

The concept of polypharmacy encompasses adverse drug reactions and non-adherence factors in elderly individuals. It also leads to the increased use of healthcare services and negative health outcomes. The problem is further alleviated by the odds of potentially inappropriate medications (PIM), which lead to the development of drug-related problems. Since polypharmacy is more commonly observed in the elderly population, urgency is required to introduce operative protocols for preventing and managing this problem. The family medicine model of care can be associated with favorable illness outcomes regarding satisfaction with consultation, treatment adherence, self-management behaviors, adherence to medical advice, and healthcare utilization. Hence, interventions built on family medicine models can provide significant support in improving the outcomes of the older population and their quality of life. In this regard, the authors have taken up the task of explaining the accessible resources which can be availed to improve the application of health care services in the field of geriatric medicine.

A higher incidence of diabetic peripheral neuropathy may be associated with decreased sleep and increased depression in older adults

Aim: Diabetes mellitus (DM) tends to increase with aging. Nearly half of the patients with DM develop neuropathy (DPN). Despite its high burden and morbidity, the conditions that DPN may be associated with have not been adequately studied in older adults. We aimed to identify sleep duration and comprehensive geriatric assessment components that may be associated with DPN. Material and Method: This is a cross-sectional retrospective study. DPN diagnosed with a medical history, neurologic examination, and electromyography (EMG). 125 diabetic older patients were included. All comprehensive geriatric assessment tests and questions about sleep quality and time were performed. We divided the patients into two groups those without neuropathy and with neuropathy and compared them. Results: The median age of 125 patients was 72 (min-max; 64-94). 58.8% of them were women. The percentage of married people and living with their spouse and slept for 6 hours or more had a lower percentage in the DPN group. Polypharmacy and the percentage of heart failure were significantly higher in the DPN group. Lawton-Brody score, which shows instrumental daily living activities (IADL) and geriatric depression score (GDS) was higher in the DPN group. In logistic regression, we found that depression scores were higher and sleep duration was shorter in the DPN group (respectively, odd ratio:265 p:.012; odd ratio:.1.917 p:.045) Conclusions: DPN in older adults may affect the functionality and be associated with fewer sleep hours and depression. Not only blood glucose regulation but also other factors such as sleep duration and depressed mood may be associated with DPN in older adults.

Reimbursed Medication Adherence Enhancing Interventions in European Countries: Results of the EUREcA Study

Introduction: Current literature lacks detailed understanding of the reimbursement framework of medication adherence enhancing interventions (MAEIs). As part of the ENABLE COST Action, the EUREcA (“EUropen REimbursement strategies for interventions targeting medication Adherence”) study aimed to provide an in-depth overview of reimbursed MAEIs currently available in European countries at national and regional levels and to pave the way for further MAEIs to be implemented in the future.

Methods: A web-based, cross-sectional survey was performed across 38 European countries and Israel. The survey questionnaire was developed as a result of an iterative process of discussion informed by a desk review. The survey was performed among invited ENABLE collaborators from June to July 2021. Besides descriptive analysis, association between country income and health care expenditure, and the availability of reimbursed MAEIs were also assessed.

Results: The survey identified 13 reimbursed MAEIs in nine countries: multi-dose drug dispensing (n = 5), medication review (n = 4), smart device (n = 2), mobile application (n = 1), and patient education (n = 1). The median GDP per capita of countries having ≥1 reimbursed MAEI was significantly higher compared to countries having no reimbursed adherence intervention (33,888 EUR vs 16,620 EUR, respectively; p = 0.05).

Conclusions: Our findings highlight that to date only a small number of MAEIs have been reimbursed in European countries. Comprehensive health technology assessment recommendations and multi-stakeholder collaboration could help removing barriers related to the implementation and reimbursement of MAEIs.

Multiple Medication Adherence and Related Outcomes in Community-Dwelling Older People on Chronic Polypharmacy: A Retrospective Cohort Study on Administrative Claims Data

Poor medication adherence compromises treatment efficacy and adversely affects patients' clinical outcomes. This study aims to assess (1) multiple medication adherence to the most common drug classes chronically prescribed to older people, (2) the factors associated, and (3) the clinical outcomes. This retrospective cohort study included 122,655 community-dwelling patients aged 65-94 years old, newly exposed to chronic polypharmacy, and recorded in the Lombardy Region (northern Italy) administrative database from 2016 to 2018. Multiple medication adherence was assessed for drugs for diabetes, antithrombotics, antihypertensives, statins, and bisphosphonates, by calculating the daily polypharmacy possession ratio (DPPR). One-year mortality, nursing home, emergency department (ED), and hospital admission rates were calculated for 2019. The most prescribed drugs were antihypertensives (89.0%). The mean (std.dev) DPPR was 82.9% (15.6). Being female (OR = 0.85, 95%CI: 0.84-0.86), age ≥85 years (OR = 0.77, 95%CI: 0.76-0.79), and multimorbidity (≥4 diseases, OR = 0.88, 95%CI: 0.86-0.90) were associated with lower medication adherence. A higher DPPR was associated with clinical outcomes-in particular, improved survival (HR = 0.93 for 10/100-point increase, 95%CI: 0.92-0.94) and lower incidence in nursing home admissions (SDHR = 0.95, 95%CI: 0.93-0.97). Adherence to the most common chronic drugs co-prescribed to the older population was high. Better multiple medication adherence was associated with better clinical outcomes.

Medication Adherence Among Patients with Multimorbidity in the United Arab Emirates

Background

Multimorbidity, defined as having two or more chronic diseases, has a major impact on public health and Sustainable Development Goals (SDG). This study aims to assess the prevalence of medication adherence and associated factors among patients with multimorbidity.

Methods

A questionnaire-based, cross-sectional survey was conducted by a trained interviewer across patients with multimorbidity attending outpatient clinics in two tertiary referral hospitals in the United Arab Emirates (UAE). Demographic and social variables and the outcome (self-reported adherence to long-term medication) were measured using the General Medication Adherence Scale (GMAS). Multiple logistic regression was used to assess medication adherence and associated factors.

Results

From a total of 630 participants included in this study, the estimated prevalence of high medication adherence is 78.57% (±1.63478) with a 95% confidence interval (CI) [75.19, 81.61]. The odds of high medication adherence increased with age. The odds of high medication adherence for patients aged 66 years and older than those aged 19-35 years is adjusted odds ratio (AOR) = 3.880, with a 95% CI [1.124, 13.390]. Patients with income more than 50,000 had the odds, AOR = 5.169 with a 95% CI [1.282, 20.843], compared to those earning less than 10,000 Dirhams (AED). Patients aged 36-65 with health insurance coverage had higher medication adherence than groups on the other end. The number of current medications is significantly (p-value = 0.027) associated with high medication adherence with the odds of high medication adherence, AOR = 4.529 with a 95% CI [1.184, 17.326], the highest for those currently taking four medications.

Conclusion

This study highlights younger population having multimorbidity in the context of an increasing life expectancy and suboptimal therapeutic outcomes. Furthermore, the study highlights multimorbidity is associated with low medication adherence and out-of-pocket payment, and non-availability of insurance is a major hindrance to medication adherence.

Polypharmacy in Older People With Heart Failure: Roles of the Geriatrician and Pharmacist

Heart failure (HF) is a common health condition that typically affects older adults. Many people with HF are cared for on an inpatient basis, by noncardiologists, such as acute medical physicians, geriatricians and other physicians. Treatment options for HF are ever increasing, and adherence to guidelines for prognostic therapy contributes to polypharmacy, which is very familiar to clinicians who care for older people. This article explores the recent trials in both HF with reduced ejection fraction and HF with preserved ejection fraction and the limitations of international guidance in their management with respect to older people. In addition, this article discusses the challenge of managing polypharmacy in those with advanced age, and the importance of involving a geriatrician and pharmacist in the HF multidisciplinary team to provide a holistic and person-centred approach to optimisation of HF therapies.

Prevalence of Chronic Polypharmacy in Community-Dwelling Elderly People in Poland: Analysis of National Real-World Database Helps to Identify High Risk Group

Introduction: Multimorbidity often comes with age, making elderly people particularly prone to polypharmacy. Polypharmacy, in turn, is a risk factor for adverse drug reactions, drug-drug interactions, non-adherence to medication, negative health outcomes, and increased healthcare services utilization. The longer the exposure to polypharmacy is, the higher the risk of these consequences is. Therefore, a detailed assessment of the prevalence and drivers of chronic polypharmacy in the elderly is particularly important. Aim of study: To find out the prevalence of chronic polypharmacy in the elderly population of Poland, and to characterize the subgroup with the highest risk of this problem, using real-world data. Methodology: A retrospective analysis of data on dispensation and healthcare services utilization held by the national payer organization for the year 2018. Chronic polypharmacy was defined as possession, as a result of dispensation, of five or more prescribed drugs within 80% of each of the consecutive 6 months. Results: Chronic polypharmacy was found in 554.1 thousand patients, i.e. in 19.1% of the national 65+ cohort. On average, those patients were 76 years old, and 49.3% of them were female. The vast majority (68.6%) continued their polypharmacy for the period of the whole year. There was a marked variation in geographical distribution of chronic polypharmacy with the highest value of 1.7 thousand per 100,000 inhabitants in the Łódź Voivodeship. Patients exposed to chronic polypharmacy filled prescriptions from 4.5±2.36 healthcare professionals. The average number of drugs they used was 8.3±3.84 DDD per patient per day. The most often prescribed drugs were Metformin, Atorvastatin and Pantoprazole. The average annual hospitalisation rate in those patients was 1.03±2.4. Conclusion: This study was the first of this kind involving a nationwide assessment of chronic polypharmacy in Polish elderly people. We found that this problem affected one fifth of Polish older adults and it remains stable due to its direct relation to chronic conditions. Thus, our results confirm that this phenomenon is highly important for the national health policy and requires relevant interventions. The planned introduction of pharmaceutical care in Poland is expected to help in solving the problem.