Multi-Morbidity and Polypharmacy in Older People: Challenges and Opportunities for Clinical Practice

Proud but Powerless: A Qualitative Study of Homecare Workers´ Work Experiences and Their Suggestions for How Care for Homebound Older Adults Can Be Improved

Many older adults with complex care needs live at home due to ageing-in-place policies. This study explored homecare workers' experiences and suggestions for improvements of care. Twelve semi-structured interviews were analyzed thematically, and revealed pride, capability, and satisfaction in their work, yet they feel undervalued and lack support. They advocate for integrated care models, recognition of their competence, flexible work approaches, and committed leadership. This would enhance patient care and address their own working conditions, addressing concerns from being relegated to the bottom of the hierarchy. They emphasize the need for comprehensive approaches, spanning from housekeeping to end-of-life palliative care.

Neuro-ophthalmic challenges and multi-morbidity in vasculitis among the older adults

INTRODUCTION

Vasculitides are a heterogeneous group of disorders producing inflammation of blood vessels (e.g. arteries or veins). All major vasculitides potentially have ophthalmological symptoms and signs including visual loss. Co-morbidity, multimorbidity, polypharmacy, and geriatric syndromes all play important roles in patient outcomes for these rheumatic conditions in the elderly. This monograph reviews the NCBI PubMed database (Feb 2023) literature on the neuro-ophthalmic and geriatric considerations in vasculitis.

AREAS COVERED

Cogan Syndrome, Granulomatosis with Polyangiitis, Giant Cell Arteritis, Polyarteritis Nodosa, Takayasu Arteritis, Vasculitis epidemiology, and neuro-ophthalmological symptoms.

EXPERT OPINION

Geriatric patient care for vasculitis with neuro-ophthalmological manifestations can be complicated by the interplay of multiple co-morbidities, polypharmacy, and specific geriatric syndromes. The valuation and treatment of vasculitis and the complications associated with the disease can negatively impact patient care. Advances in noninvasive imaging and updates in diagnostic criteria have enabled increased identification of patients at earlier stages with less severe disease burden. Novel therapeutic agents can be glucocorticoid sparing and might reduce the adverse effects of chronic steroid use. Holistic care models like the 5 M geriatric care model (mind, mobility, medications, multicomplexity, and matters most) allow patients' needs to be in the forefront with biopsychosocial aspects of a patient being addressed.

Prevalence and Sociodemographic Correlates of Chronic Pain Among A Nationally Representative Sample of Older Adults in the United States

Subgroup analyses conducted among U.S. national survey data have estimated that 27-34% of adults aged ≥65 years have chronic pain. However, none of these studies focused specifically on older adults or examined disparities in chronic pain in those aged ≥65 years. To obtain current information on the prevalence and sociodemographic correlates of chronic pain in U.S. older adults, a cross-sectional analysis was conducted of data collected from 3,505 older adults recruited from the AmeriSpeak® Panel. Chronic pain was defined as pain on most or every day in the last three months. Nationally representative chronic pain prevalence estimates were computed by incorporating study-specific survey design weights. Logistic regression analyses evaluated differences in chronic pain status as a function of sociodemographic characteristics (e.g., gender, race/ethnicity, socioeconomic status). Results indicated that 37.8% of older adults reported chronic pain. Compared to White older adults, Black (OR = 0.6, 95% CI: 0.4-0.8) and Asian (OR = 0.2, 95% CI: 0.1-0.8) older adults were less likely to report chronic pain. The prevalence of chronic pain was also lower among those who reported the highest (vs. lowest) household income (OR = 0.6, 95% CI: 0.4-0.8). Those who were not working due to disability (vs. working as a paid employee) were more likely to report chronic pain (OR = 3.2, 95% CI: 2.1-5.0). This study was the first to recruit a large, representative sample of older adults to estimate the prevalence of chronic pain and extends prior work by identifying sub-groups of older adults that are disproportionately affected. PERSPECTIVE: This study was the first to estimate the prevalence and sociodemographic correlates of chronic pain among a large, representative sample of U.S. older adults. Findings underscore the high prevalence of chronic pain and highlight disparities in chronic pain prevalence rates among this historically understudied population.

Prevalence of compliance with PIMDINAC criteria among elderly people living with HIV and in non-infected outpatients with other chronic diseases

BACKGROUND

There is a high prevalence of multimorbidity and polypharmacy among older people, especially in people living with HIV (PLWH) with an increased life expectancy due to effective antiretroviral therapy (ART). Consequently, there is a higher risk of potentially inappropriate medications (PIM), potential drug-drug interactions (DI), and problems of non-adherence to treatment (NAC) in older PLWH. PIMDINAC criteria (potentially inappropriate medications (PIM), drug-drug interactions (DI), and non-adherence to treatment (NAC)) purport to jointly analyse these problems. The purpose of the study was to compare the prevalence of PIMDINAC criteria among elderly PLWH and non-infected patients with chronic diseases, and to determine whether HIV infection constitutes a predictor of the presence of PIMDINAC criteria, totally or partially.

METHODS

A cross sectional study was conducted between February and June 2020. HIV positive patients aged ≥65 years were compared with a group of patients with chronic conditions attending the outpatient hospital pharmacy service.

RESULTS

The study involved 140 patients: 47 HIV positive and 93 HIV negative, and mean age was 69 versus 73 years, respectively (p=0.062). The prevalence of total PIMDINAC criteria was similar between the groups (12.5 vs 10.8%, p=0.505). In relation to inappropriate medication, no differences were observed between groups (48.9 vs 55.9%, p=0434). Drug-drug interactions were higher in patients with chronic conditions (52.7 vs 25.5%, p=0.002) compared with non-adherence, which was higher in people with HIV (22.6 vs 65.6%, p<0.001). No differences in polypharmacy (≥6 and 11 drugs) rates were observed.

CONCLUSIONS

PIMDINAC criteria were highly prevalent in older PLWH, similar to non-infected patients. HIV infection in older people was associated with a lower risk of drug-drug interactions. However, non-adherence was a risk factor compared with age matched controls. Deprescribing strategies, including a capability-motivation-opportunity pharmaceutical care model based intervention should be implemented in clinical routines.

Building an effective medicines optimisation model: a health system approach

This commentary narrates on the building of an effective and innovative medicines optimisation model. It discusses the essential features, emphasizes the need, and considers the strong health and pharmacy system as a prerequisite before such a model could be built. The paper argues that it is important to strengthen the health system before the elements of pharmaceutical care and medicine optimisation can take shape. It discusses the discourse and interplay between medicine use and medicine access research. The other important elements to include are the "selection of medicines by health technology assessment", "economic evaluation of pharmacy services", "pharmacists' remuneration by the government", "Health system strengthening status", "quality use of generic medicines programmes", "rationale prescribing", "access to medicines and medicines pricing", "medicines advertising" and the "state of pharmacy practice and the development of the pharmacist's role". A set of different high-, middle- and low-income countries are used to provide examples of the status of the health system and the subsequent development of pharmacy practice and medicines optimisation. The countries include the UK, Australia, New Zealand, Pakistan, Türkiye, Malaysia, India, and Pakistan.

Association of Drug-Disease Interactions with Mortality or Readmission in Hospitalised Middle-Aged and Older Adults: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Multimorbidity is common in hospitalised adults who are at increased risk of inappropriate prescribing including drug-disease interactions. These interactions occur when a medicine being used to treat one condition exacerbates a concurrent medical condition and may lead to adverse health outcomes. The aim of this review was to examine the association between drug-disease interactions and the risk of mortality and readmission in hospitalised middle-aged and older adults.

METHODS

A systematic review was conducted on drug-disease interactions in hospitalised middle-aged (45-64 years) and older adults (≥65 years). The study protocol was prospectively registered with PROSPERO (Registration Number: CRD42022341998). Drug-disease interactions were defined as a medicine being used to treat one condition with the potential to exacerbate a concurrent medical condition or that were inappropriate based on a comorbid medical condition. Both observational and interventional studies were included. The outcomes of interest were mortality and readmissions. The databases searched included MEDLINE, CINAHL, EMBASE, Web of Science, SCOPUS and the Cochrane Library from inception to 12 July, 2022. A meta-analysis was performed to pool risk estimates using the random-effects model.

RESULTS

A total of 563 studies were identified and four met the inclusion criteria. All were observational studies in older adults, with no studies identified in middle-aged adults. Most of the studies were at risk of bias because of an inadequate adjustment for covariates and a lack of clarity around individuals lost to follow-up. There were various definitions of drug-disease interactions within these four studies. Two studies assessed drugs that were contraindicated based on renal function, one assessed an individual drug-disease combination, and one was based on the clinical judgement of a pharmacist. There were two studies that showed an association between drug-disease interactions and the outcomes of interest. One reported that the use of diltiazem in patients with heart failure was associated with an increased risk of readmissions. The second reported that the use of medicines contraindicated according to renal function were associated with increased risk of all-cause mortality and a composite of mortality and readmission. Three of the studies (total study population = 5705) were amenable to a meta-analysis, which showed no significant association between drug-disease interactions and readmissions (odds ratio = 1.0, 95% confidence interval 0.80-1.38).

CONCLUSIONS

Few studies were identified examining the risk of drug-disease interactions and mortality and readmission in hospitalised adults. Most of the identified studies were at risk of bias. There is no universal accepted definition of drug-disease interactions in the literature. Further studies are needed to develop a standardised and accepted definition of these interactions to guide further research in this area.

Medications and cognitive risk in Aboriginal primary care: a cross-sectional study

BACKGROUND

Aboriginal and Torres Strait Islander people are ageing with high rates of comorbidity, yet little is known about suboptimal prescribing in this population.

AIM

The prevalence of potentially suboptimal prescribing and associated risk factors were investigated among older patients attending primary care through Aboriginal Community Controlled Health Services (ACCHSs).

METHODS

Medical records of 420 systematically selected patients aged ≥50 years attending urban, rural and remote health services were audited. Polypharmacy (≥ 5 prescribed medications), potentially inappropriate medications (PIMs) as per Beers Criteria and anticholinergic burden (ACB) were estimated and associated risk factors were explored with logistic regression.

RESULTS

The prevalence of polypharmacy, PIMs and ACB score ≥3 was 43%, 18% and 12% respectively. In multivariable logistic regression analyses, polypharmacy was less likely in rural (odds ratio (OR) = 0.43, 95% confidence interval (CI) = 0.24-0.77) compared to urban patients, and more likely in those with heart disease (OR = 2.62, 95% CI = 1.62-4.25), atrial fibrillation (OR = 4.25, 95% CI = 1.08-16.81), hypertension (OR = 2.14, 95% CI = 1.34-3.44), diabetes (OR = 2.72, 95% CI = 1.69-4.39) or depression (OR = 1.91, 95% CI = 1.19-3.06). PIMs were more frequent in females (OR = 1.88, 95% CI = 1.03-3.42) and less frequent in rural (OR = 0.41, 95% CI = 0.19-0.85) and remote (OR = 0.58, 95% CI = 0.29-1.18) patients. Factors associated with PIMs were kidney disease (OR = 2.60, 95% CI = 1.37-4.92), urinary incontinence (OR = 3.00, 95% CI = 1.02-8.83), depression (OR = 2.67, 95% CI = 1.50-4.77), heavy alcohol use (OR = 2.83, 95% CI = 1.39-5.75) and subjective cognitive concerns (OR = 2.69, 95% CI = 1.31-5.52). High ACB was less common in rural (OR = 0.10, 95% CI = 0.03-0.34) and remote (OR = 0.51, 95% CI = 0.25-1.04) patients and more common in those with kidney disease (OR = 3.07, 95% CI = 1.50-6.30) or depression (OR = 3.32, 95% CI = 1.70-6.47).

CONCLUSION

Associations between potentially suboptimal prescribing and depression or cognitive concerns highlight the importance of considering medication review and deprescribing for these patients.

Comparative analysis of the prevalence 3-HIT concept in people living with HIV and seronegative patients with chronic conditions. Cross-3HIT Project

OBJECTIVES

This study aimed to assess and compare the occurrence of 3-HIT in people living with HIV (PLWH) and seronegative patients. Additionally, the study investigated whether HIV infection could serve as a predictor of the presence of 3-HIT.

METHODS

A cross-sectional study was conducted between December 2022 and January 2023 to compare PLWH with a group of seronegative patients with chronic diseases attending an outpatient hospital pharmacy service. The 3-HIT concept encompasses the simultaneous presence of non-adherence to concomitant treatment (NAC), drug-drug interactions (DDIs), and high pharmacotherapeutic complexity in polymedicated patients. The assessment of 3-HIT compliance included NAC, evaluated using both the Morisky-Green questionnaire and electronic pharmacy dispensing records. DDIs were analysed using the Liverpool University and Micromedex databases. Pharmacotherapeutic complexity was measured using the Medication Regimen Complexity Index (MRCI) tool. Logistic regression analysis was performed to identify independent factors related to 3-HIT. Additionally, an explanatory logistic model was created to investigate whether HIV infection, along with other adjustment variables, could predict compliance with the 3-HIT concept.

RESULTS

The study included 145 patients: 75 PLWH and 70 seronegative patients. The median age was 40 versus 39 years, respectively (p=0.22). Seronegative patients exhibited a higher prevalence of NAC (p<0.01). HIV infection was identified as a protective factor in the context of DDIs (p<0.01). Male sex (p<0.01) and age (p=0.01) were identified as being associated with an MRCI ≥11.25 points. A higher prevalence of 3-HIT was observed in seronegative patients (18.7% vs 48.6%, p<0.01). However, the developed regression model identified HIV infection as a risk factor associated with an increased likelihood of 3-HIT (OR 4.00, 95% CI 1.88 to 8.52, p<0.01).

CONCLUSIONS

The 3-HIT concept exhibited a high prevalence among seronegative patients with chronic diseases, with HIV infection identified as a predicted risk factor for NAC and the development of 3-HIT.

Factors That Influence Quality of Life in Postmenopausal Osteoporotic Women With Nonvertebral Fractures: The Guardian Angel Multicenter Longitudinal Study

The knowledge of variables associated with quality of life in women with nonvertebral fractures is poor. The aim of this study was to examine the independent associations between sociodemographic and clinical factors, self-care, and quality of life in this specific population. We undertook a 3-year multicenter longitudinal study on a cohort of Italian postmenopausal osteoporotic women with three follow-ups at 1, 3, and 6 months. Nurses asked women to complete questionnaires on quality of life and self-care. The sample (n = 532) had a mean age of 74.78 years. The results showed that women taking more than two medications per day (p = .026) and those with nine or more years of education (p = .036) were more likely to exhibit better quality of life levels (p < .001) than their counterparts. Both self-care and quality of life scores improved over time in all participants. This study shows positive independent associations between quality of life and polypharmacy, education, and self-care behaviors, which were improved by educational interventions to attain a better quality of life in our participants.

Older adult's experiences of navigating healthcare whilst living with multimorbidity

OBJECTIVE

The way older adults navigate their healthcare is critical to supporting positive health outcomes. However, navigating healthcare with multimorbidity is typically disjointed due to complexities in treatment, management, and service provision. This study sought to examine how older patients navigate healthcare whilst living with multimorbidity.

METHODS AND MEASURES

Semi-structured interviews were undertaken with five older adults, aged 65 or older, living with multimorbidity in residential care in England. An Interpretive Phenomenological Analysis was undertaken.

RESULTS

Overall, participants experienced navigating healthcare whilst living with multimorbidity as challenging. Group Experiential Themes included 'Health knowledge and understanding', 'Relationships and expectations' and 'Navigating health care with a single lens'. Collectively these themes represented narratives involving how having limited understanding of health conditions, experiencing challenges in communication with health professionals, and receiving segmented care in a health care system driven by a single condition focus interfered with navigation.

CONCLUSION

These findings highlight experiences of older adults living with multimorbidity navigating healthcare and illustrate several ways older adults living with multimorbidity may be supported to navigate services with less challenges. The research also promotes the need for future research in this area.

Homecare workers - an untapped resource in preventing emergency department visits among older individuals? A qualitative interview study from Sweden

BACKGROUND

Older individuals with functional decline and homecare are frequent visitors to emergency departments (ED). Homecare workers (HCWs) interact regularly with their clients and may play a crucial role in their well-being. Therefore, this study explores if and how HCWs perceive they may contribute to the prevention of ED visits among their clients.

METHODS

In this qualitative study, 12 semi-structured interviews were conducted with HCWs from Sweden between July and November 2022. Inductive thematic analysis was used to identify barriers and facilitators to prevent ED visits in older home-dwelling individuals.

RESULTS

HCWs want to actively contribute to the prevention of ED visits among clients but observe many barriers that hinder them from doing so. Barriers refer to care organisation such as availability to primary care staff and information transfer; perceived attitudes towards HCWs as co-workers; and client-related factors. Participants suggest that improved communication and collaboration with primary care and discharge information from the ED to homecare services could overcome barriers. Furthermore, they ask for support and geriatric education from primary care nurses which may result in increased respect towards them as competent staff members.

CONCLUSIONS

HCWs feel that they have an important role in the health management of older individuals living at home. Still, they feel as an untapped resource in the prevention of ED visits. They deem that improved coordination and communication between primary care, ED, and homecare organisations as well as proactive care would enable them to add significantly to the prevention of ED visits.

Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review

Multimorbidity (multiple conditions) and polypharmacy (multiple medications) are increasingly common, yet there is a need to better understand the prevalence of co-occurrence. In this systematic review, we examined the prevalence of multimorbidity and polypharmacy among adults (≥18 years) and older adults (≥65 years) in clinical and community settings. Six electronic databases were searched, and 87 studies were retained after two levels of screening. Most studies focused on adults 65 years and older and were done in population-based community settings. Although the operational definitions of multimorbidity and polypharmacy varied across studies, consistent cut-points (two or more conditions and five or more medications) were used across most studies. In older adult samples, the prevalence of multimorbidity ranged from 4·8% to 93·1%, while the prevalence of polypharmacy ranged from 2·6% to 86·6%. High heterogeneity between studies indicates the need for more consistent reporting of specific lists of conditions and medications used in operational definitions.

Development and validation of prognostic machine learning models for short- and long-term mortality among acutely admitted patients based on blood tests

Several scores predicting mortality at the emergency department have been developed. However, all with shortcomings either simple and applicable in a clinical setting, with poor performance, or advanced, with high performance, but clinically difficult to implement. This study aimed to explore if machine learning algorithms could predict all-cause short- and long-term mortality based on the routine blood test collected at admission.

METHODS

We analyzed data from a retrospective cohort study, including patients > 18 years admitted to the Emergency Department (ED) of Copenhagen University Hospital Hvidovre, Denmark between November 2013 and March 2017. The primary outcomes were 3-, 10-, 30-, and 365-day mortality after admission. PyCaret, an automated machine learning library, was used to evaluate the predictive performance of fifteen machine learning algorithms using the area under the receiver operating characteristic curve (AUC).

RESULTS

Data from 48,841 admissions were analyzed, of these 34,190 (70%) were randomly divided into training data, and 14,651 (30%) were in test data. Eight machine learning algorithms achieved very good to excellent results of AUC on test data in a of range 0.85-0.93. In prediction of short-term mortality, lactate dehydrogenase (LDH), leukocyte counts and differentials, Blood urea nitrogen (BUN) and mean corpuscular hemoglobin concentration (MCHC) were the best predictors, whereas prediction of long-term mortality was favored by age, LDH, soluble urokinase plasminogen activator receptor (suPAR), albumin, and blood urea nitrogen (BUN).

CONCLUSION

The findings suggest that measures of biomarkers taken from one blood sample during admission to the ED can identify patients at high risk of short-and long-term mortality following emergency admissions.

Determinants of multimorbidity in older adults in Iran: a cross-sectional study using latent class analysis on the Bushehr Elderly Health (BEH) program

BACKGROUND AND OBJECTIVES

Multimorbidity, defined as the presence of two or more long-term health conditions in an individual, is one of the most significant challenges facing health systems worldwide. This study aimed to identify determinants of classes of multimorbidity among older adults in Iran.

RESEARCH DESIGN AND METHODS

In a cross-sectional sample of older adults (aged ≥ 60 years) from the second stage of the Bushehr Elderly Health (BEH) program in southern Iran, latent class analysis (LCA) was used to identify patterns of multimorbidity. Multinomial logistic regression was conducted to investigate factors associated with each multimorbidity class, including age, gender, education, household income, physical activity, smoking status, and polypharmacy.

RESULTS

In 2,426 study participants (mean age 69 years, 52% female), the overall prevalence of multimorbidity was 80.2%. Among those with multimorbidity, 3 latent classes were identified. These comprised: class 1, individuals with a low burden of multisystem disease (56.9%); class 2, individuals with predominantly cardiovascular-metabolic disorders (25.8%) and class 3, individuals with predominantly cognitive and metabolic disorders (17.1%). Compared with men, women were more likely to belong to class 2 (odds ratio [OR] 1.96, 95% confidence interval [CI] 1.52-2.54) and class 3 (OR 4.52, 95% CI 3.22-6.35). Polypharmacy was associated with membership class 2 (OR 3.52, 95% CI: 2.65-4.68) and class 3 (OR 1.84, 95% CI 1.28-2.63). Smoking was associated with membership in class 3 (OR 1.44, 95% CI 1.01-2.08). Individuals with higher education levels (59%) and higher levels of physical activity (39%) were less likely to belong to class 3 (OR 0.41; 95% CI: 0.28-0.62) and to class 2 (OR 0.61; 95% CI: 0.38-0.97), respectively. Those at older age were less likely to belong to class 2 (OR 0.95).

DISCUSSION AND IMPLICATIONS

A large proportion of older adults in Iran have multimorbidity. Female sex, polypharmacy, sedentary lifestyle, and poor education levels were associated with cardiovascular-metabolic multimorbidity and cognitive and metabolic multimorbidity. A greater understanding of the determinants of multimorbidity may lead to strategies to prevent its development.

The development and evaluation of a medication diary to report problems with medication use

Purpose

The study aimed to develop and evaluate a medication diary for patients to report problems with medication use to enable shared-decision making and improve medication adherence.

Methods

Based on a search for existing diaries, a review of the content, and a list of medication self-management problems compiled from previous research, a paper and pencil version of a medication diary was developed. The diary was reviewed for clarity and overall presentation by five healthcare providers and nine patients. Afterwards, user-friendliness was evaluated by 69 patients with polypharmacy discharged from hospital during a quantitative prospective study.

Results

The medication diary consists of several parts: (1) a medication schedule allowing patients to list their medicines, (2) information sheets allowing patients to write down specific medication-related information, (3) a monthly overview to indicate daily whether medication-related problems were experienced, (4) problem sheets elaborating on the problems encountered, (5) space for specific medication-related questions for healthcare providers to facilitate shared-decision making. The review phase resulted in minor textual adjustments and one extra problem in the problem sheet. Most participants, who tested the medication diary for two months, found the diary user-friendly (80%) and easy to fill in (89%). About 40% of participants reported problems with medication use. Half of the patients indicated that the diary can facilitate discussing problems with healthcare providers.

Conclusion

The medication diary offers patients the opportunity to report problems regarding their medication use in a proven user-friendly manner and to discuss these problems with healthcare providers. Reporting and discussing problems with medication use can serve as a first step towards making shared decisions on how to address the problems encountered.

Prescribing cascades in ambulatory care: A structured synthesis of evidence

The strength of evidence for specific ambulatory care prescribing cascades, in which a marker drug is used to treat an adverse event caused by an index drug, has not been well characterized. To perform a structured, systematic, and transparent review of the evidence supporting ambulatory care prescribing cascades. Ninety-four potential prescribing cascades identified through a previously published systematic review. Systematic search of the literature to further characterize prescribing cascades. (1) Grading of evidence based on observational studies investigating associations between index and marker drugs, including: Level I-strong evidence [i.e. multiple high-quality studies]; Level II-moderate evidence [i.e. single high-quality study]; Level III-fair evidence [no high-quality studies but one or more moderate-quality studies]; and Level IV-poor evidence [other]. (2) Listing of the adverse event associated with the index drug in the product's United States Food and Drug Administration (FDA) label. (3) Synthesis of the evidence supporting mechanisms linking index drugs and associated adverse events. Of 99 potential cascades, 94 were supported by one or more confirmatory observational studies and were therefore included in this review. The 94 cascades related to 30 types of adverse drug reactions affecting 10 different anatomic/physiologic systems and were investigated by a total of 88 confirmatory studies, including prescription sequential symmetry analysis (n = 51), cohort (n = 30), and case-control (n = 7) studies. Overall, the evidence from observational studies was strong for 18 (19.1%) prescribing cascades, moderate for 61 (64.9%), fair for 13 (13.8%), and poor for 2 (2.1%). Although the evidence supporting mechanisms that link index drugs and associated adverse events was variable, FDA labels included information about the adverse event associated with the index drug for most (n = 86) but not all of the 94 prescribing cascades. Although we identified 18 of 94 prescribing cascades supported by strong clinical evidence and most adverse events associated with index drugs are included in FDA label, the evidentiary basis for prescribing cascades varies, with many requiring further evidence of clinical relevance.

Problems experienced when swallowing solid oral dosage forms in older Japanese patients with dysphagia: A cross-sectional study

AIMS

We aimed to assess the difficulty in taking solid oral dosage forms (SODFs) among older people with dysphagia and clarify the relationship between difficulty in swallowing SODFs and swallowing function.

METHODS AND RESULTS

Outpatients from a dysphagia clinic aged ≥65 years were asked yes-or-no questions about the applicability of eight items regarding difficulty in taking SODFs. Additionally, a videofluorographic swallowing study (VFSS) was performed to assess their swallowing function. The Kruskal-Wallis test and Spearman's rank correlation coefficient were used to analyze the relationship between difficulty in taking SODFs and swallowing function.

RESULTS

Among the 93 participants, the average number of SODFs consumed was 5.8 ± 3.1. In the questionnaire, the average number of "yes" answers was 2.2 ± 2.2, and 65 patients (71.0%) answered "yes" to at least one question. Additionally, no significant relationship was observed between the perceived difficulty in swallowing SODFs and VFSS findings.

CONCLUSION

Approximately 70% of participants reported subjective difficulty in taking SODFs, showing that patients uniformly reported perceived difficulty in taking SODFs regardless of actual swallowing function. The results of this study suggest that patients must be questioned thoroughly about their SODFs use, regardless of the objective severity of their dysphagia.

Physical activity influences adherence to pharmacological treatments in patients with severe mental disorders: results from the multicentric, randomized controlled LIFESTYLE trial

Introduction: Poor adherence to pharmacological treatment is frequent in people with severe mental disorders and it often causes lack of effectiveness of many psychotropic drugs. Thus, efforts should be made to improve adherence to pharmacological treatments in patients with these disorders. Methods: In this paper, based on the LIFESTYLE randomized, controlled multicentric trial, we aim to: 1) assess the level of adherence in a real-world sample of patients with severe mental disorders; 2) evaluate differences in treatment adherence according to patients' socio-demographic and clinical characteristics; 3) evaluate the impact of an innovative psychosocial intervention, on patients' adherence to treatments. The Lifestyle Psychosocial Group Intervention consists of group sessions, focused on different lifestyle behaviours, including healthy diet; physical activity; smoking habits; medication adherence; risky behaviours; and regular circadian rhythms. At end of each session a 20-min moderate physical activity is performed by the whole group. Results: The sample consists of 402 patients, mainly female (57.1%, N = 229), with a mean age of 45.6 years (±11.8). Less than 40% of patients reported a good adherence to pharmacological treatments. Adherence to treatments was not influenced by gender, age, diagnosis and duration of illness. At the end of the intervention, patients receiving the experimental intervention reported a significant improvement in the levels of adherence to treatments (T0: 35.8% vs. T3: 47.6%, p < 0.005). Patients practicing moderate physical activity reported a two-point improvement in the levels of adherence [odds ratio (OR): 1,542; 95% confidence intervals (CI): 1,157-2,055; p < 0.001], even after controlling for several confounding factors. Discussion: The experimental lifestyle intervention, which can be easily implemented in the routine clinical practice of mental health centres, was effective in improving adherence to pharmacological treatments.

Healthcare for Older Adults with Multimorbidity: A Scoping Review of Reviews

Purpose

To summarize adverse healthcare outcomes experienced by older adults with multimorbidity and barriers perceived by stakeholders regarding the healthcare systems primarily designed to address individual health conditions. Healthcare elements that aim to provide coordinated, continuous, and comprehensive services for this population were also identified.

Patients and Methods

We applied the methodology framework developed by Arksey and O'Malley to guide the review. The three-step search strategy was used to identify relevant English reviews that focused on adverse healthcare outcomes and barriers encountered by older adults with multimorbidity and other stakeholders regarding the single-disease-focused healthcare systems, as well as those concentrated on healthcare elements that aim to provide coordinated, continuous, and comprehensive services for older adults with multimorbidity. Five electronic databases, including PubMed/Medline, CINAHL, Web of Science Core Collection, Cochrane Library, and Embase, were systematically searched from database inception to February 2022. A standardized table was used to extract data. Thematic analysis was then conducted under the guidance of the Rainbow Model of Integrated Care and the Chronic Care Model.

Results

Twenty reviews were included in this study. Therapeutic competitions, high healthcare service utilization, and high healthcare costs were three adverse healthcare outcomes experienced by patients. Both patients and healthcare professionals faced various barriers. Other stakeholders, including informal caregivers, healthcare managers, and policymakers, also perceived several barriers. Numerous healthcare elements were identified that may contribute to optimized services. The elements most frequently mentioned included the implementation of shared decision-making, comprehensive geriatric assessments, and individual care plans.

Conclusion

This study conducted a comprehensive overview of the current knowledge related to healthcare for older adults with multimorbidity. In the future, it is necessary to develop more coordinated, continuous, and comprehensive healthcare service delivery models based on the healthcare needs of older adults with multimorbidity and the specific characteristics of different countries.

Benefits of deprescribing for older people with frailty and polypharmacy: part one

The UK population is ageing rapidly, a trend that is likely to continue due to improvements in chronic disease management and increased life expectancy. Comorbidities, including frailty, become increasingly common with age and as a result it is likely that multiple medicines will be prescribed for older people, leading to polypharmacy. This is a concern because polypharmacy is associated with various adverse effects and an increased medicine burden in this population, as well as a financial burden for the healthcare system. This article, the first of two parts, explains the physiology of ageing and frailty, and considers the adverse effects of polypharmacy on older people with frailty, using a fictional case study to illustrate this. Part two will use the case study to explore the use of medication reviews and deprescribing benefits as part of medicines optimisation.

Development of a patient-centred medication management model for polymedicated home-dwelling older adults after hospital discharge: results of a mixed methods study

OBJECTIVE

This study aimed to investigate medication management among polymedicated, home-dwelling older adults after discharge from a hospital centre in French-speaking Switzerland and then develop a model to optimise medication management and prevent adverse health outcomes associated with medication-related problems (MRPs).

DESIGN

Explanatory, sequential, mixed methods study based on detailed quantitative and qualitative findings reported previously.

SETTING

Hospital and community healthcare in the French-speaking part of Switzerland.

PARTICIPANTS

The quantitative strand retrospectively examined 3 years of hospital electronic patient records (n=53 690 hospitalisations of inpatients aged 65 years or older) to identify the different profiles of those at risk of 30-day hospital readmission and unplanned nursing home admission. The qualitative strand explored the perspectives of older adults (n=28), their informal caregivers (n=17) and healthcare professionals (n=13) on medication management after hospital discharge.

RESULTS

Quantitative results from older adults' profiles, affected by similar patient-related, medication-related and environment-related factors, were enhanced and supported by qualitative findings. The combined findings enabled us to design an interprofessional, collaborative medication management model to prevent MRPs among home-dwelling older adults after hospital discharge. The model comprised four interactive fields of action: listening to polymedicated home-dwelling older adults and their informal caregivers; involving older adults and their informal caregivers in shared, medication-related decision-making; empowering older adults and their informal caregivers for safe medication self-management; optimising collaborative medication management practices.

CONCLUSION

By linking the retrospective and prospective findings from our explanatory sequential study involving multiple stakeholders' perspectives, we created a deeper comprehension of the complexities and challenges of safe medication management among polymedicated, home-dwelling older adults after their discharge from hospital. We subsequently designed an innovative, collaborative, patient-centred model for optimising medication management and preventing MRPs in this population.

Polypharmacy and Excessive Polypharmacy Among Persons Living with Chronic Pain: A Cross-Sectional Study on the Prevalence and Associated Factors

Purpose

Polypharmacy can be defined as the concomitant use of ≥5 medications and excessive polypharmacy, as the use of ≥10 medications. Objectives were to (1) assess the prevalence of polypharmacy and excessive polypharmacy among persons living with chronic pain, and (2) identify sociodemographic and clinical factors associated with excessive polypharmacy.

Patients and Methods

This cross-sectional study used data from 1342 persons from the ChrOnic Pain trEatment (COPE) Cohort (Quebec, Canada). The self-reported number of medications currently used by participants (regardless of whether they were prescribed or taken over-the-counter, or were used for treating pain or other health issues) was categorized to assess polypharmacy and excessive polypharmacy.

Results

Participants reported using an average of 6 medications (median: 5). The prevalence of polypharmacy was 71.4% (95% CI: 69.0-73.8) and excessive polypharmacy was 25.9% (95% CI: 23.6-28.3). No significant differences were found across gender identity groups. Multivariable logistic regression revealed that factors associated with greater chances of reporting excessive polypharmacy (vs <10 medications) included being born in Canada, using prescribed pain medications, and reporting greater pain intensity (0-10) or pain relief from currently used pain treatments (0-100%). Factors associated with lower chances of excessive polypharmacy were using physical and psychological pain treatments, reporting better general health/physical functioning, considering pain to be terrible/feeling like it will never get better, and being employed.

Conclusion

Polypharmacy is the rule rather than the exception among persons living with chronic pain. Close monitoring and evaluation of the different medications used are important for all persons, especially those with limited access to care.

Medication and Road Test Performance Among Cognitively Healthy Older Adults

Importance

Older adults are increasingly prescribed medications that have adverse effects. Prior studies have found a higher risk of motor vehicle crashes to be associated with certain medication use.

Objective

To determine whether specific medication classes were associated with performance decline as assessed by a standardized road test in a community sample of cognitively healthy older adults, to evaluate additional associations of poor road test performance with comorbid medical conditions and demographic characteristics, and to test the hypothesis that specific medication classes (ie, antidepressants, benzodiazepines, sedatives or hypnotics, anticholinergics, antihistamines, and nonsteroidal anti-inflammatory drugs or acetaminophen) would be associated with an increase in risk of impaired driving performance over time.

Design, Setting, and Participants

This was a prospective cohort study of 198 cognitively healthy adults 65 years and older with a valid driver's license who were followed up annually, with rolling enrollment. Data were collected from participants in St Louis, Missouri, and neighboring Illinois who were enrolled in the Knight Alzheimer's Disease Research Center. Data were collected from August 28, 2012, to March 14, 2023, and analyzed from April 1 to 25, 2023. Participants with healthy cognition, defined as a Clinical Dementia Rating score of 0 at baseline and subsequent visits, who had available clinical, neuropsychological, road tests, and self-reported medication data were included.

Exposure

Potentially driver-impairing medication use.

Main Outcomes and Measures

The primary outcome measure was performance on the Washington University Road Test (pass or marginal/fail). Multivariable Cox proportional hazards models were used to evaluate associations between potentially driver-impairing medication use and road test performance.

Results

Of the 198 included adults (mean [SD] baseline age, 72.6 [4.6] years; 87 female [43.9%]), 70 (35%) received a marginal/fail rating on the road test over a mean (SD) follow-up of 5.70 (2.45) years. Any use of antidepressants (adjusted hazard ratio [aHR], 2.68; 95% CI, 1.69-4.71), serotonin and norepinephrine reuptake inhibitors (aHR, 2.68; 95% CI, 1.54-4.64), sedatives or hypnotics (aHR, 2.70; 95% CI, 1.40-5.19), or nonsteroidal anti-inflammatory drugs (aHR, 2.72; 95% CI, 1.31-5.63) was associated with an increase in risk of receiving a marginal/fail rating on the road test compared with control individuals. Conversely, participants taking lipid-lowering agents had a lower risk of receiving a marginal/fail rating compared to control individuals. There were no statistically significant associations found between anticholinergic or antihistamines and poor performance.

Conclusions and Relevance

In this prospective cohort study, specific medication classes were associated with an increase in risk of poor road test performance over time. Clinicians should consider this information and counsel patients accordingly when prescribing these medications.

Trajectories in chronic disease accrual and mortality across the lifespan in Wales, UK (2005-2019), by area deprivation profile: linked electronic health records cohort study on 965,905 individuals

Background

Understanding and quantifying the differences in disease development in different socioeconomic groups of people across the lifespan is important for planning healthcare and preventive services. The study aimed to measure chronic disease accrual, and examine the differences in time to individual morbidities, multimorbidity, and mortality between socioeconomic groups in Wales, UK.

Methods

Population-wide electronic linked cohort study, following Welsh residents for up to 20 years (2000-2019). Chronic disease diagnoses were obtained from general practice and hospitalisation records using the CALIBER disease phenotype register. Multi-state models were used to examine trajectories of accrual of 132 diseases and mortality, adjusted for sex, age and area-level deprivation. Restricted mean survival time was calculated to measure time spent free of chronic disease(s) or mortality between socioeconomic groups.

Findings

In total, 965,905 individuals aged 5-104 were included, from a possible 2.9 m individuals following a 5-year clearance period, with an average follow-up of 13.2 years (12.7 million person-years). Some 673,189 (69.7%) individuals developed at least one chronic disease or died within the study period. From ages 10 years upwards, the individuals living in the most deprived areas consistently experienced reduced time between health states, demonstrating accelerated transitions to first and subsequent morbidities and death compared to their demographic equivalent living in the least deprived areas. The largest difference were observed in 10 and 20 year old males developing multimorbidity (-0.45 years (99% CI: -0.45, -0.44)) and in 70 year old males dying after developing multimorbidity (-1.98 years (99% CI: -2.01, -1.95)).

Interpretation

This study adds to the existing literature on health inequalities by demonstrating that individuals living in more deprived areas consistently experience accelerated time to diagnosis of chronic disease and death across all ages, accounting for competing risks.

Funding

UK Medical Research Council, Health Data Research UK, and Administrative Data Research Wales.

Interprofessional collaboration in a community virtual ward: A focus group study

BACKGROUND

The problem of a lack of nurses is expected to worsen in the future. With an ever-increasing number of elderly patients with multimorbidity and a shortage of healthcare professionals, primary care must innovatively organise their services to offer more sustainable healthcare services. Organising healthcare services in a community virtual ward has been found to improve the quality of life for vulnerable elderly populations.

AIM

The aim of the study was to explore healthcare professionals' experiences of interprofessional collaboration in care for patients with multimorbidity in a community virtual ward in the Norwegian context.

METHODS

Focus group interviews were conducted in this qualitative exploratory study. A purposive sample of 17 healthcare professionals working in a community virtual ward in Norway was interviewed. Data were analysed using thematic analysis.

RESULTS

The study results show that healthcare professionals recognise a need for patient involvement in the community virtual ward to offer more sustainable healthcare services at home. Furthermore, the results show how healthcare professionals experience the use of assessment tools and whiteboard meetings as useful tools for facilitating interprofessional collaboration. The study results also describe how interprofessional and holistic follow-up with patients with multimorbidity contributes to increased focus on health promotion in the community virtual ward.

CONCLUSION

We found that interprofessional collaboration in community virtual wards may be a sustainable way of organising healthcare services for patients with multimorbidity living at home. Interprofessional collaboration with a patient-centred and health promotion approach, seems to increase the quality of the follow-up for patients with multimorbidity living at home. Additionally, mutual interprofessional trust and respect seems to be essential for making use of the unique expertise of different professions in the follow-up for patients with multimorbidity. In the future, both the patient's voice and opinion of their next of kin should be considered in the development of more sustainable homecare services.

Managing drugs with anticholinergic activity

Over the past two decades, considerable data have emerged on an association between drugs with anticholinergic activity and serious adverse effects in older people. Well-recognised anticholinergic adverse effects include dry mouth, blurred vision, constipation and urinary retention. Of particular concern is the potential impact on cognitive function with several studies showing that long-term use of medicines with anticholinergic activity is associated with worsening of cognitive function, increased incidence of dementia and increased mortality. This article gives an overview of the evidence, discusses some of the tools used to identify high-risk drugs and highlights issues to consider when prescribing drugs with anticholinergic activity with a view to reducing potential risks in older people and those at highest risk of cognitive impairment.

Effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity: a scoping review

BACKGROUND

Chronic ultimorbidity is the most frequent and serious health problem in older adults. Home visiting programmes could be a strategy with potential benefits. However, there are no scoping reviews to date that examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

OBJECTIVE

To examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

METHODS

A scoping review was carried out following PRISMA-ScR reporting guidelines. The search was conducted in six databases (PubMed/Medline, Cochrane, CINAHL, Web of Science, Scopus and EMBASE) between October 2021 and April 2022.

RESULTS

Four RCTs with 560 patients were included. The visits were carried out by nurses, nursing students, volunteers, and other healthcare professionals. The interventions varied in the number of visits, frequency, duration of follow-up, and whether or not they were combined with other strategies such as telephone calls. Discrepancies were found in the effects of the interventions on quality of life, self-efficacy, self-rated health, and use and cost of health and social services.

CONCLUSION

This review shows that home visiting programmes could have potential benefits for older adults with chronic multimorbidity. However, its results have been inconclusive. There is a need for high quality studies involving a larger number of patients, in which home visits are the main intervention.

Complex interventions for improving independent living and quality of life amongst community-dwelling older adults: a systematic review and meta-analysis

BACKGROUND

community-based complex interventions for older adults have a variety of names, including Comprehensive Geriatric Assessment, but often share core components such as holistic needs assessment and care planning.

OBJECTIVE

to summarise evidence for the components and effectiveness of community-based complex interventions for improving older adults' independent living and quality of life (QoL).

METHODS

we searched nine databases and trial registries to February 2022 for randomised controlled trials comparing complex interventions to usual care. Primary outcomes included living at home and QoL. Secondary outcomes included mortality, hospitalisation, institutionalisation, cognitive function and functional status. We pooled data using risk ratios (RRs) or standardised mean differences (SMDs) with 95% confidence intervals (CIs).

RESULTS

we included 50 trials of mostly moderate quality. Most reported using holistic assessment (94%) and care planning (90%). Twenty-seven (54%) involved multidisciplinary care, with 29.6% delivered mainly by primary care teams without geriatricians. Nurses were the most frequent care coordinators. Complex interventions increased the likelihood of living at home (RR 1.05; 95% CI 1.00-1.10; moderate-quality evidence) but did not affect QoL. Supported by high-quality evidence, they reduced mortality (RR 0.86; 95% CI 0.77-0.96), enhanced cognitive function (SMD 0.12; 95% CI 0.02-0.22) and improved instrumental activities of daily living (ADLs) (SMD 0.11; 95% CI 0.01-0.21) and combined basic/instrumental ADLs (SMD 0.08; 95% CI 0.03-0.13).

CONCLUSIONS

complex interventions involving holistic assessment and care planning increased the chance of living at home, reduced mortality and improved cognitive function and some ADLs.

The effect of polypharmacy on healthcare services utilization in older adults with comorbidities: a retrospective cohort study

BACKGROUND

Older adults are more prone to increasing comorbidities and polypharmacy. Polypharmacy is associated with inappropriate prescribing and an increased risk of adverse effects. This study examined the effect of polypharmacy in older adults on healthcare services utilization (HSU). It also explored the impact of different drug classes of polypharmacy including psychotropic, antihypertensive, and antidiabetic polypharmacy on HSU.

METHODS

This is a retrospective cohort study. Community-dwelling older adults aged ≥ 65 years were selected from the primary care patient cohort database of the ambulatory clinics of the Department of Family Medicine at the American University of Beirut Medical Center. Concomitant use of 5 or more prescription medications was considered polypharmacy. Demographics, Charlson Comorbidity index (CCI), and HSU outcomes, including the rate of all-cause emergency department (ED) visits, rate of all-cause hospitalization, rate of ED visits for pneumonia, rate of hospitalization for pneumonia, and mortality were collected. Binomial logistic regression models were used to predict the rates of HSU outcomes.

RESULTS

A total of 496 patients were analyzed. Comorbidities were present in all patients, with 22.8% (113) of patients having mild to moderate comorbidity and 77.2% (383) of patients having severe comorbidity. Patients with polypharmacy were more likely to have severe comorbidity compared to patients with no polypharmacy (72.3% vs. 27.7%, p = 0.001). Patients with polypharmacy were more likely to visit the ED for all causes as compared to patients without polypharmacy (40.6% vs. 31.4%, p = 0.05), and had a significantly higher rate of all-cause hospitalization (adjusted odds ratio aOR 1.66, 95 CI = 1.08-2.56, p = 0.022). Patients with psychotropic polypharmacy were more likely to be hospitalized due to pneumonia (crude odds ratio cOR 2.37, 95 CI = 1.03-5.46, p = 0.043), and to visit ED for Pneumonia (cOR 2.31, 95 CI = 1.00-5.31, p = 0.049). The association lost significance after adjustment.

CONCLUSIONS

The increasing prevalence of polypharmacy amongst the geriatric population with comorbidity is associated with an increase in HSU outcomes. As such, frequent medication revisions in a holistic, multi-disciplinary approach are needed.

Potentially inappropriate medications in nursing homes and the community older adults using the French health insurance databases

PURPOSE

Potentially inappropriate medications (PIMs) have become a major issue in improving prescribing practices and reducing the risk of adverse drug events in older people. However, very few studies have compared exposition to PIMs controlling for differences in demographic and health between nursing home residents (NHRs) and community-dwelling older adults (CDOAs). This study aimed to assess the prescribing pattern of PIMs between NHRs and CDOAs.

METHODS

We conducted a cross-sectional study over three months in 2019 using the French Health Insurance databases. The study population included 274 971 NHRs and 4 893 721 CDOAs aged 75 years or over. The prevalence ratio (PR) between NHRs and CDOAs of 17 PIM indicators, based on the Beers and STOPP criteria lists, was assessed using multivariable robust Poisson regression adjusted for age, sex, diseases, and polypharmacy.

RESULTS

During the study period, 54% of NHRs and 29% of CDOAs received at least one PIM. After adjustment, the prevalence of PIMs was 33% higher among NHRs compared to CDOAs (aPR = 1.33; 95% CI [1.33-1.34]). NHRs received PIMs related to benzodiazepines (aPR = 1.43; 95% CI [1.42-1.43]), anticholinergic drugs (aPR = 1.29; 95% CI [1.27-1.31]), and at least three central nervous system-active drugs (aPR = 1.94; 95% CI [1.92-1.96]) more frequently. Prevalence of PIMs related to non-steroidal anti-inflammatory drugs (aPR = 0.50; 95% CI [0.48-0.52]) and long-acting benzodiazepines (aPR = 0.84; 95% CI [0.82-0.85]) was lower among NHRs.

CONCLUSION

The NHRs were at greater risk for PIM than CDOAs, although differences exist according to the category of PIMs. As the population is aging, it is essential to promote and evaluate interventions in NHs and the community to enhance medication optimization.

Frailty and polypharmacy in the community-dwelling elderly with multiple chronic diseases

BACKGROUND

Both multi-morbidity (MM) and polypharmacy (PP) are common in the elderly and pose a challenge for health and social care systems. However, high-quality patient-centred care requires context-bound understanding of the patterns and use of medications in those with MM. Therefore, the aim of this study was to investigate the prevalence of PP in community-dwelling elderly, and the factors associated with MM, PP, excessive polypharmacy (EPP), and the types of drugs used.

METHODS

We analysed data of 164 community-dwelling subjects aged ≥60 years from January to December 2020 at a general hospital in a rural area of Taiwan. MM was defined as >4 diagnoses of chronic health conditions. Non-polypharmacy (NP), PP, and EPP were defined as <5, 5-8, and >8 prescriptions, respectively. Other variables including basic activities of daily living (BADL), severity of frailty, depressive mood, screening for intellectual impairment, and nutritional status were also analysed.

RESULTS

Of the 164 participants, 34.8% had >4 diagnoses, 66.5% had PP, and 26.2% had EPP. The patients with >4 diagnoses had worse performance in BADL, higher levels of frailty, and more prescriptions than those with fewer diagnoses. The EPP group had worse performance in BADL, a higher level of frailty, more comorbidities, and higher prevalences of diabetes mellitus and chronic kidney disease compared to the NP and PP groups. After adjusting for covariates, we further found a higher number of medications associated with having more comorbidities, and a higher level of frailty associated with having a greater number of medications.

CONCLUSION

We found relationships between frailty and PP, and between PP and MM, but frailty did not associate with MM. Since frailty, PP, and MM may be viewed as an inevitable trinity of ageing, reducing PP could be a method to both prevent frailty and disentangle this trinity in the elderly.

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.

Pill-Burden and its Association with Treatment Burden among Patients with Advanced Stages of Chronic Kidney Disease

Introduction

Chronic kidney disease (CKD) is associated with multimorbidity and high treatment burden. Pill-burden is one component of the overall treatment burden. However, little is known about its magnitude and contribution to the overall treatment burden among patients with advanced stages of CKD. This study aimed to quantify the magnitude of pill-burden in dialysis-dependent vs. non-dialysis-dependent advanced-stage CKD patients and its association with treatment burden.

Methods

This was a cross-sectional study for the assessment of pill-burden and treatment burden among non-dialysis and hemodialysis (HD)-dependent CKD patients. Pill-burden was quantified as "number of pills/patient/week" through electronic medical record, while treatment burden was assessed using the "Treatment Burden Questionnaire (TBQ)". Furthermore, oral and parenteral medication burden was also quantified. Data were analyzed using both descriptive and inferential analysis, including Mann - Whitney U test and two-way between groups analysis of variance (ANOVA).

Results

Among the 280 patients included in the analysis, the median (IQR) number of prescribed chronic medications was 12 (5.7) oral and 3 (2) parenteral medications. The median (IQR) pill-burden was 112 (55) pills/week. HD patients experienced higher pill-burden than non-dialysis patients [122 (61) vs. 109 (33) pills/week]; however, this difference did not reach statistical significance (p = 0.81). The most commonly prescribed oral medications were vitamin D (90.4%), sevelamer carbonate (65%), cinacalcet (67.5%), and statins (67.1%). Overall, patients who had high pill-burden (≥112 pills/week) had significantly higher perceived treatment burden compared to low pill-burden patients (<112 pills/week) [47(36.2) vs. 38.5(36.7); p = 0.0085]. However, two-way ANOVA showed that dialysis status is the significant contributor to the treatment-burden in the high overall pill-burden group (p < 0.01), the high oral-medication-burden group (p < 0.01), and the high parenteral-medication-burden group (p = 0.004).

Conclusions

Patients with advanced CKD experienced a high pill-burden, which increases the treatment burden; however, the dialysis status of the patient is the main factor affecting the overall treatment burden. Future intervention studies should target this population with an aim to reduce polypharmacy, pill-burden, and treatment burden, which may ultimately improve CKD patients' quality of life.

Perspectives on medication safety from vulnerable older migrants and their relatives-A qualitative explorative study

Little is known about the combined effect of several risk factors occurring simultaneously, and the perspectives of patients with language barriers or dementia are lacking because these patients are often excluded as research participants. This study aimed at investigating medication safety among older migrants with cognitive disorders who use five or more medications daily from the perspective of older patients and their relatives. Eight semi-structured interviews with patients and relatives were conducted in their homes. The study adopted an inductive hermeneutic phenomenological approach and used both "Analyzing the present" and "Systematic text condensation" as inspiration for the analysis. Three main themes were identified: (i) potential medication safety and threats, (ii) communication and missing medication information and (iii) everyday life with medication. Threats to medication safety included medication perceptions, health perceptions, and cognitive impairment of the patient as well as miscommunication among departments, wrong diagnosis and medication, and unlocked medication cabinets. However, most families expressed having no problems concerning medication, which could be a result of limited engagement of the patient and relatives in the medical treatment and limited medication information provided to the families by healthcare professionals.

Association between multiple chronic conditions and insufficient health literacy: cross-sectional evidence from a population-based sample of older adults living in Switzerland

BACKGROUND

Health literacy is the ability to find, understand, assess, and apply health information. Individuals suffering from multiple chronic conditions have complex healthcare needs that may challenge their health literacy skills. This study aimed to investigate the relationship between multimorbidity, the number of chronic conditions, and health literacy levels in a sample of adults aged 58+ in Switzerland.

METHODS

We used data from 1,615 respondents to a paper-and-pencil questionnaire administered as part of wave 8 (2019/2020) of the Survey of Health, Ageing and Retirement in Europe (SHARE) in Switzerland. Health literacy was measured using the short version of the European Health Literacy Survey questionnaire. The final score ranged from 0 to 16 and was categorised into three health literacy levels: inadequate (0-8), problematic (9-12), and sufficient (13-16). The number of chronic conditions was self-reported based on a pre-defined list. Associations were examined using multivariable ordinary least squares and ordered probit regression models, controlling for key socio-demographic characteristics.

RESULTS

Overall, 63.5% of respondents reported having at least one chronic condition. Respondents who reported one, two, and three or more chronic conditions were more likely to have lower health literacy scores compared to respondents who did not report any chronic condition (p<0.05, p<0.01, and p<0.001, respectively). Suffering from two and three or more chronic conditions (vs. no chronic condition) was significantly associated with a higher likelihood of having inadequate or problematic health literacy levels (both p-values <0.01).

CONCLUSIONS

Our findings suggest a need to improve health literacy in older adults suffering from chronic conditions. Improved health literacy could constitute a promising lever to empower individuals to better self-manage their health to ultimately reduce the double burden of chronic diseases and insufficient health literacy in this vulnerable population.

Polypharmacy and Multimorbidity in the Urogynecology Population and Their Effect on Pelvic Floor Symptoms

IMPORTANCE

Polypharmacy and multimorbidity are common in older adults but has not been well studied in the urogynecologic patient population.

OBJECTIVES

The objective of this study was to determine the prevalence of polypharmacy and multimorbidity in a diverse outpatient urogynecologic population and to examine whether polypharmacy and/or multimorbidity were associated with lower urinary tract symptoms, pelvic organ prolapse, defecatory distress, and/or female sexual dysfunction.

STUDY DESIGN

This is a secondary analysis of a dual-center cross-sectional study of new patients presenting for evaluation of pelvic floor disorders at 2 urban academic outpatient urogynecology clinics. Baseline demographics and clinical characteristics were obtained from the electronic medical record. Validated surveys were administered to determine severity of lower urinary tract symptoms (Overactive Bladder Validated 8-Question Screener, Urogenital Distress Inventory-6), pelvic floor dysfunction (Pelvic Organ Prolapse Distress Inventory-6, Colorectal-Anal Distress Inventory-8), and sexual dysfunction (6-item Female Sexual Function Index). Standard statistical techniques were used.

RESULTS

One hundred ninety-seven women with mean age 58.8 years (SD, 13.4 years) were included, and most were of minority race/ethnicity (Black, 34.0%; Hispanic, 21.8%). The majority of participants met criteria for polypharmacy (58.4%) and multimorbidity (85.8%), with a mean prescription number of 6.5 (SD, ± 4.9) and mean number of medical comorbidities of 4.9 (SD, ± 3.3). Polypharmacy and multimorbidity were significantly associated with higher CRADI-8 scores. Specifically, polypharmacy was associated with straining with bowel movements and painful stools, whereas multimorbidity was associated with incomplete emptying and fecal urgency. There was no significant association between polypharmacy and multimorbidity with urinary symptoms, prolapse, or sexual dysfunction.

CONCLUSIONS

Polypharmacy and multimorbidity are common in the urogynecologic population. There is a relationship between greater defecatory distress and polypharmacy and multimorbidity.

THE FRAMEWORK OF THE PILOT PROJECT FOR TESTING A TELEMEDICINE MODEL IN THE FIELD OF GERIATRICS - HEALTH CHALLENGES AND JUSTIFICATION OF THE PROJECT IMPLEMENTATION

OBJECTIVE

Aim: To present the essentials of the pilot project for testing a telemedicine model in the field of geriatrics, along with a snapshot of the health challenges.

PATIENTS AND METHODS

Materials and Methods: This review paper use the synthetic method summarizing the main objectives of the telemedicine project in the field of geriatrics. The described project involving telemedical care of patients with geriatric complexes in the area of frailty syndrome, sarcopenia and malnutrition, according to the proposed model addresses the aforementioned problems. The project provides a holistic model of home and outpatient care, which will allow concerting on 3 groups of the above-mentioned geriatric syndromes. The project will have a pilot character and is aimed at clinical verification through the introduction (implementation) of the new method and accompanying organizational and technological solutions (platform, equipment) in an area where current models and schemes of therapeutic and diagnostic support were insufficient.

CONCLUSION

Conclusions: The implementation of telemedicine solutions creates an opportunity for geriatric patients and their families by improving access to specialized medical care. This project will support patients, but also caregivers, who (through training and telemedicine) will be better able to provide care services with the ability to reconcile them with their own work.

Adherence to antimalarials and glucocorticoids treatment and its association with self-reported disease activity in systemic lupus erythematosus patients

OBJECTIVES

We aimed to investigate the rate of non-adherence to antimalarials and glucocorticoids (GCs) and to analyze their potential relationships with sociodemographic characteristics, disease activity and accumulate damage in a cohort of Systemic lupus erythematosus (SLE) patients.

METHODS

A cross-sectional study was conducted among 670 patients. The Systemic Lupus Erythematosus Activity Questionnaire (SLAQ) and the Lupus Damage Index Questionnaire (LDIQ) were used to assess disease activity and accumulated damage.

RESULTS

The prevalence of non-adherence to antimalarials and GCs were 10.67% and 39.61%. 86.9% of participants indicated that the reason for stopping therapy was the presence of side effects. SLE patients with non-adherence to antimalarials and GCs had significantly higher scores in disease severity (SLAQ) compared to adherence patients (5.03 (2.12) vs 4.39 (2.61); p = .004 and (4.75 (2.29) vs 4.05 (2.78); p ≤ .001).

CONCLUSION

Adherence to the treatment indicated in SLE differs from drug to drug. Findings highlight the importance of developing interventions to support adherence and improve outcomes among patients.

General practitioners' perceptions of pharmacists working in general practice: a qualitative interview study

BACKGROUND

Pharmacists are being increasingly employed as part of general practice teams globally, and their input has been associated with several clinical and economic benefits. However, there is a paucity of research focussing on general practitioners' (GPs') perceptions of pharmacist integration into practices in countries where this novel role for pharmacists is yet to become commonplace.

OBJECTIVE

To explore GPs' perceptions of integrating pharmacists into general practices and to identify the behavioural determinants of GPs integrating pharmacists into practices.

METHODS

Semistructured interviews were conducted with GPs practising in Ireland, who were sampled using a combination of purposive, convenience, and snowball sampling. Interviews were audio-recorded and transcribed verbatim, which then were analysed using conventional content analysis and directed content analysis employing the Theoretical Domains Framework (TDF).

RESULTS

Seventeen GPs were interviewed between November 2021 and February 2022. Seven TDF domains were identified as predominant in influencing GPs' perceptions of pharmacist integration into general practices. These perceptions were mostly positive, especially regarding patient outcomes, cost savings, and improving access to care. However, there were concerns about funding the role, affecting others' workloads, and pharmacists' training needs to work in practices.

CONCLUSION

This study's theory-informed insight provides a deeper understanding of GPs' perceptions of pharmacists working in general practice and behaviours which can be targeted to help optimize integration. These findings should be utilized in future service development to preempt and address GPs' concerns ahead of pharmacist integration, as well as to inform the development of general practice-based pharmacist roles going forward.

Multiple Long-Term Conditions (MLTC) and the Environment: A Scoping Review

Background: Multiple Long Term conditions (MLTC) are a major health care challenge associated with high service utilisation and expenditure. Once established, the trajectory to an increased number and severity of conditions, hospital admission, increased social care need and mortality is multifactorial. The role of wider environmental determinants in the MLTC sequelae is unclear. Aim: the aim of this review was to summarise and collate existing evidence on environmental determinants on established MLTC. Methods: comprehensive search of Medline, Embase, Cochrane, CINAHL and Bielefeld Academic Search Engine (BASE), from inception to 4th June 2022 in addition to grey literature. Two authors independently screened and extracted papers. Disagreements were resolved with a third author. Results: searches yielded 9079 articles, 12 of which met the review's inclusion criteria. Evidence of correlations between some environmental determinants and increased or decreased risks of MLTC were found, including the quality of internal housing/living environments, exposure to airborne environmental hazards and a beneficial association with socially cohesive, accessible and greener neighbourhood environments. Conclusions: The majority of the 12 included papers focused on the built and social environments. The review uncovered very limited evidence, indicating a need for further research to understand the role of environmental determinants in MLTC.

Culture, theory-of-mind, and morality: How independent and interdependent minds make moral judgments

Although the investigation of the neural mechanisms of morality has increased in recent years, the neural underpinnings of cultural variations in judgments of morality is understudied. In this paper, we propose that the well-established cultural differences in two cognitive processes, consideration of mental state and causal attribution, would lead to differences in moral judgment. Specifically, North Americans rely heavily on the mental state of a protagonist and dispositional attributions, whereas East Asians focus more on situational attributions and place less emphasis on the mental state of a protagonist. These differences would be accounted for by activity in brain regions implicated in thinking about others' minds, or theory-of-mind (ToM), which would underlie the cultural shaping of moral judgment. This proposed cultural neuroscience approach may broaden the scope of morality research, better predict moral behavior, and reduce disparities in diverse groups' moral judgment.

Associations of osteoporosis and sarcopenia with frailty and multimorbidity among participants of the Hertfordshire Cohort Study

BACKGROUND

Ageing is commonly associated with sarcopenia (SP) and osteoporosis (OP), both of which are associated with disability, impaired quality of life, and mortality. The aims of this study were to explore the relationships between SP, OP, frailty, and multimorbidity in community-dwelling older adults participating in the Hertfordshire Cohort Study (HCS) and to determine whether coexistence of OP and SP was associated with a significantly heavier health burden.

METHODS

At baseline, 405 participants self-reported their comorbidities. Cut-offs for low grip strength and appendicular lean mass index were used according to the EWSGOP2 criteria to define SP. OP was diagnosed when T-scores of < -2.5 were present at the femoral neck or the participant reported use of the anti-OP medications including hormone replacement therapy (HRT), raloxifene, or bisphosphonates. Frailty was defined using the standard Fried definition.

RESULTS

One hundred ninety-nine men and 206 women were included in the study. Baseline median (interquartile range) age of participants was 75.5 (73.4-77.9) years. Twenty-six (8%) and 66 (21.4%) of the participants had SP and OP, respectively. Eighty-three (20.5%) reported three or more comorbidities. The prevalence of pre-frailty and frailty in the study sample was 57.5% and 8.1%, respectively. Having SP only was strongly associated with frailty [odds ratio (OR) 8.28, 95% confidence interval (CI) 1.27, 54.03; P = 0.027] while the association between having OP alone and frailty was weaker (OR 2.57, 95% CI 0.61, 10.78; P = 0.196). The likelihood of being frail was substantially higher in the presence of coexisting SP and OP (OR 26.15, 95% CI 3.13, 218.76; P = 0.003). SP alone and OP alone were both associated with having three or more comorbidities (OR 4.71, 95% CI 1.50, 14.76; P = 0.008 and OR 2.86, 95% CI 1.32, 6.22; P = 0.008, respectively) although the coexistence of SP and OP was not significantly associated with multimorbidity (OR 3.45, 95% CI 0.59, 20.26; P = 0.171).

CONCLUSIONS

Individuals living with frailty were often osteosarcopenic. Multimorbidity was common in individuals with either SP or OP. Early identification of SP and OP not only allows implementation of treatment strategies but also presents an opportunity to mitigate frailty risk.

The Impact of Drug Interactions in Patients with Community-Acquired Pneumonia on Hospital Length of Stay

(1) Background: An aging society is frequently affected by multimorbidity and polypharmacy, which, in turn, leads to an increased risk for drug interaction. The aim of this study was to evaluate the influence of drug interactions on the length of stay (LOS) in hospitals. (2) Methods: This retrospective, single-centre study is based on patients treated for community-acquired pneumonia in the hospital. Negative binomial regression was used to analyse the association between drug interactions and the LOS in the hospital. (3) Results: The total cohort contained 503 patients, yet 46 inpatients (9%) that died were not included in the analyses. The mean age was 74 (±15.3) years, 35% of patients older than 65 years were found to have more than two drug interactions, and 55% had a moderate, severe, or contraindicated adverse drug reaction. The regression model revealed a significant association between the number of drug interactions (rate ratio (RR) 1.02; 95%-CI 1.01–1.04) and the severity of drug interactions (RR 1.22; 95%-CI 1.09–1.37) on the LOS for the overall cohort as well as for the subgroup of patients aged 80 years and older. (4) Conclusion: Drug interactions are an independent risk factor for prolonged hospitalisation. Standardised assessment tools to avoid drug interactions should be implemented in clinical routines.

Decreasing trends in potentially inappropriate medications in older people: a nationwide repeated cross-sectional study

Background

Potentially Inappropriate Medications (PIMs) and polypharmacy are widely used indicators of suboptimal prescribing for older people. The aim of this study was to describe the changes in the prevalence of PIMs and polypharmacy among people aged 75 years and over between 2011 and 2019 in France.

Methods

PIMs and polypharmacy were assessed among people aged 75 years and over every two years between 2011 and 2019 using the French health insurance data system. Sixteen PIM criteria from the 2015 Beers and STOPP lists were assessed. Polypharmacy (5 to 9 drugs) and hyper-polypharmacy (≥10 drugs) were defined based on the average number of drugs dispensed per quarter. The Annual Percent Change (APC) and 95%CI were assessed using linear regression models after standardization of the prevalence on age and sex.

Results

The study population included 5,777,645 individuals over 75 years old in 2011 and 6,328,155 in 2019. The prevalence of PIMs decreased from 49.6 to 39.6% over the study period (APC: − 1.19% [− 1.35;-1.04]). Of the sixteen indicators assessed, the prevalence of thirteen decreased between 2011 and 2019. Benzodiazepines were the most frequent PIMs (34.7% in 2011 to 26.9% in 2019), followed by anticholinergic drugs (12.1% in 2011 to 8.3% in 2019), oral non-steroidal anti-inflammatory drugs (11.4 to 7.8%), and PIMs related to antihypertensive drugs (7.4 to 6.0%). Overall, women and individuals aged 85 years and older were more likely to receive PIMs. The prevalence of hyper-polypharmacy decreased from 30.5 to 25.9% over the study period.

Conclusion

This study, which is the first to assess the change in prevalence of PIMs and polypharmacy over time from comprehensive health data in France, highlights that PIMs and hyper-polypharmacy declined between 2011 and 2019. However, PIMs remains frequent for older people and often involves benzodiazepines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02568-1.

Analysis of the regional difference in the number of multi-drug prescriptions and its predictors in Japan, 2015-2018

Objective

Polypharmacy and multi-drug prescription are major public health problems in Japan, but only a few studies have investigated the regional differences. By revealing regional differences in the multi-drug prescriptions, we can infer regions with high rates of multimorbidity or inappropriate prescribing. This study revealed regional differences in multi-drug prescriptions (the number of simultaneous prescriptions of seven or more internal medicines) and investigated the factors affecting the difference using the National Database of Health Insurance Claims and Specific Health Checkups of Japan data.

Results

The standardized claim ratio (SCR) of the number of multi-drug prescriptions, which corrected the difference in sex and age distribution of prefectures, varied depending on prefectures. A panel data analysis investigating the association between the SCR and explanatory variables (Medical institutions, socioeconomic factors, and physical characteristics of people in prefectures) revealed that the number of public assistance recipients per 1,000 persons was positively and significantly associated with the SCR (Standardized partial regression coefficient = 0.244, p-value = 0.038). In conclusion, regional differences in the number of the multi-drug prescriptions were revealed in Japan, suggesting that public assistance recipients tend to experience multi-drug prescriptions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05787-2.

Pathophysiology and treatment of osteoporosis: challenges for clinical practice in older people

Osteoporosis, a common chronic metabolic bone disease is associated with considerable morbidity and mortality. As the prevalence of osteoporosis increases with age, a paralleled elevation in the rate of incident fragility fractures will be observed. This narrative review explores the origins of bone and considers physiological mechanisms involved in bone homeostasis relevant to management and treatment. Secondary causes of osteoporosis, as well as osteosarcopenia are discussed followed by an overview of the commonly used pharmacological treatments for osteoporosis in older people.