Influence of Education Level of Older Patients on Polypharmacy, Potentially Inappropriate Medications Listed in Beer's Criteria, and Unplanned Hospitalization: A Cross-Sectional Study in Lahore, Pakistan

Factors associated with potentially inappropriate medications in elderly with multiple myeloma

INTRODUCTION

Elderly with cancer often have multimorbidity, which determines a higher risk of polypharmacy. This is related to negative clinical results such as adverse drug reaction and emergence service visits. Furthermore, polypharmacy increases the risk of using potentially inappropriate medications.

OBJECTIVE

To evaluate the use of potentially inappropriate medication in elderly with multiple myeloma and associated factors.

METHODS

The study was conducted with older adults with multiple myeloma treated at outpatient oncology and hematology services in a southeastern Brazilian capital. Potentially inappropriate medications were classified using the American Geriatric Society/Beers 2019 Criteria. Variables were described using frequency and proportions, performing multiple logistic regression to identify factors associated with the use of potentially inappropriate medications.

RESULTS

One hundred fifty-three older adults with multiple myeloma were included, with a median age of 70.9 years. The median number of medications was 8, and 63% of patients used polypharmacy. More than half (54%) of the patients used potentially inappropriate medications, and proton pump inhibitors (46%) and benzodiazepines (8%) were the most employed therapeutic classes. Older adults who used potentially inappropriate medications differed from those who did not use them in the following characteristics: income up to three minimum wages, higher schooling level, private service, multimorbidity, hypertension, cardiovascular disease, chronic kidney disease, depression, adverse event, and polypharmacy. Higher schooling levels and polypharmacy were independently associated with the use of potentially inappropriate medications in the multivariate analysis.

CONCLUSION

Potentially inappropriate medication use was high in patients with multiple myeloma studied. The use of polypharmacy and higher schooling levels were independently and positively associated with the use of potentially inappropriate medications.

Relationship between interviewer-assisted international prostate symptom score and other objective measures of bladder outlet obstruction in Southeast Nigeria: a cross-sectional study

Introduction

there are concerns that interviewer-assisted administration of the International Prostate Symptom Score (IPSS) may introduce bias to the extent that values obtained may not correlate with the more objective measures of bladder outlet obstruction (BOO) in benign prostate enlargement (BPE). This study aims to determine the relationship between interviewer-assisted IPSS and the more objective peak urine flow rate (Qmax) and postvoid residual urine volume (PVR) in men with lower urinary tract symptoms (LUTS) due to BPE in a low-resource setting.

Methods

a cross-sectional study from July 2020 to June 2021. Using systematic random sampling, men ≥ 40 years old with LUTS attributable to uncomplicated BPE were recruited. Participants completed the English-language IPSS questionnaire with the needed assistance from the interviewer. Thereafter, the Qmax was assessed using uroflowmetry while PV and PVR were assessed using ultrasonography. Age, serum total prostate-specific antigen (tPSA), body mass index (BMI), and the highest level of formal education attained were determined. Multivariate logistic regression analysis was used to examine the relationship between these variables and IPSS.

Results

in all, 170 men of mean age 63.7±9.9 years participated. The mean PV, PVR, and Qmax were 70.84±39.50 cm3, 77.66±69.30 cm3, and 20.25±9.70ml/s, respectively. Of these 170 participants, 134 (78.8%) attained formal education beyond the primary level. Increasing points of interviewer-assisted IPSS have a strong relationship with worsening self-perceived quality of life due to LUTS (r: 0.76; p= 0.001), but a rather weak relationship with decreasing Qmax (r: -0.40; p= 0.009) and increasing PVR (r: 0.49; p= 0.005). Higher formal education was associated with lower IPSS at presentation and was statistically significant (p = 0.004). There were no predictable relationships between IPSS and age, tPSA, PV, and BMI (p > 0.05).

Conclusion

interviewer-assisted IPSS can be relied upon, but with some caution, in low-resource, low-formal education settings to give clinical information consistent with the objective measures of BOO.

Are there socioeconomic inequalities in polypharmacy among older people? A systematic review and meta-analysis

BACKGROUND

Socioeconomic status (SES) may influence prescribing, concordance and adherence to medication regimens. This review set out to investigate the association between polypharmacy and an individual's socioeconomic status.

METHODS

A systematic review and meta-analyses of observational studies was conducted across four databases. Older people (≥ 55 years) from any healthcare setting and residing location were included. The search was conducted across four databases: Medline (OVID), Web of Science, Embase (OVID) and CINAHL. Observational studies from 1990 that reported polypharmacy according to SES were included. A random-effects model was undertaken comparing those with polypharmacy (≥ 5 medication usage) with no polypharmacy. Unadjusted odds ratios (ORs), 95% confidence intervals (CIs) and standard errors (SE) were calculated for each study.

RESULTS

Fifty-four articles from 13,412 hits screened met the inclusion criteria. The measure of SES used were education (50 studies), income (18 studies), wealth (6 studies), occupation (4 studies), employment (7 studies), social class (5 studies), SES categories (2 studies) and deprivation (1 study). Thirteen studies were excluded from the meta-analysis. Lower SES was associated with higher polypharmacy usage: individuals of lower educational backgrounds displayed 21% higher odds to be in receipt of polypharmacy when compared to those of higher education backgrounds. Similar findings were shown for occupation, income, social class, and socioeconomic categories.

CONCLUSIONS

There are socioeconomic inequalities in polypharmacy among older people, with people of lower SES significantly having higher odds of polypharmacy. Future work could examine the reasons for these inequalities and explore the interplay between polypharmacy and multimorbidity.

Regional difference in multi-psychotropic drug prescription in Japan and its associated factors: an ecological study using national health insurance claims data

BACKGROUND

In Japan, regulations preventing the prescriptions of various types of psychotropic drugs have become stricter in recent years. However, the areas where multi-psychotropic drug prescriptions are common and the geographic factors that contribute to the regional difference, have not been studied. In this study, we used data from all claims in Japan to examine regional differences in the prescription for multi-psychotropic drugs using an ecological study.

METHODS

The National Database of Health Insurance Claims and Specific Health Checkups of Japan Open data in 2019 were used. The outcome was the number of prescriptions for four or more different types of anxiolytics and hypnotics as well as for three or more of the same kind of psychotropic drugs (any one of anxiolytics, hypnotics, antipsychotics, antidepressants) for outpatients in each area. Among the 335 secondary medical areas in Japan, the data on 331 areas were used in the analysis. The standardized claim ratio (SCR), an indicator of the number of this multi-psychotropic drug prescription, correcting for regional differences in distribution of population by age and sex, was calculated for each of the secondary medical areas. The spatial cluster detection technique was used to locate a cluster of high-SCR areas. Furthermore, factors associated with regional differences in the SCRs were examined by a spatial statistics model.

RESULTS

North Japanese regions tend to have high SCRs, and 13 areas in Hokkaido were identified as the most likely cluster (cluster with the highest likelihood ratio) for multi-psychotropic drug prescription. Furthermore, a spatial regression analysis revealed that the proportion of people with lower educational levels, the total number of prescriptions per capita, and the number of physicians working in psychiatric departments per capita were statistically positively associated with the SCR for the prescription of multiple psychotropic drugs.

CONCLUSIONS

It was suggested that socioeconomic and medical characteristics of areas are related to the regional variation in the multi-psychotropic drug prescriptions, however, further research using individual-level data is required to confirm these results.

Overuse of medications in low- and middle-income countries: a scoping review

Objective

To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions.

Methods

We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions.

Findings

We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives.

Conclusion

Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.

Socioeconomic Inequalities in Elective and Nonelective Hospitalizations in Older Men

IMPORTANCE

Among older adults, there is limited and inconsistent evidence on the association between socioeconomic position (SEP) and elective and nonelective hospitalization.

OBJECTIVE

To evaluate the association between SEP and all-cause and cause-specific elective and nonelective hospitalization and hospital length of stay among older men.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, prospective cohort study used data from the Concord Health and Aging in Men Project (CHAMP). CHAMP recruited 1705 men aged 70 years or older between January 28, 2005, and June 4, 2007, in Sydney, Australia. Data were analyzed from February 1 to September 30, 2021.

EXPOSURES

Indicators of SEP, including education (university degree certificate, diploma or no postschool qualifications), occupation (professionals and managers; small employers and self-employed; or lower clerical, service, sales workers, skilled, and unskilled workers), and source of income (other sources of income than government pension, reliance on government pensions and other sources of income, or reliant solely on a government pension), and a cumulative SEP score (tertiles) as SEP indicators; 3-level variables present high, intermediate, and low SEP.

MAIN OUTCOMES AND MEASURES

All-cause and cause-specific elective and nonelective hospitalizations, number of hospitalizations, and length of stay were the study outcomes, ascertained through data linkage. Associations were quantified using competing-risks survival regression and negative binomial regression.

RESULTS

A total of 1566 men (mean [SD] age, 76.8 [5.4] years) were included. During a mean (SD) 9.07 (3.53) years of follow-up, 1067 men had at least 1 elective hospitalization, and 1255 men had at least 1 nonelective hospitalization. No associations were found between SEP and elective hospitalizations. Being in the lowest tertile for educational level (subhazard ratio [SHR], 1.32; 95% CI, 1.11-1.58), occupational position (SHR, 1.30; 95% CI, 1.12-1.50), sources of income (SHR, 1.33; 95% CI, 1.17-1.52), and cumulative SEP tertile groups (SHR, 1.45; 95% CI, 1.24-1.68) were all associated with having at least 1 nonelective hospitalization compared with those in the highest tertiles. Significant associations were found between being in the lowest SEP groups and increased numbers and longer length of stay of nonelective hospitalizations.

CONCLUSIONS AND RELEVANCE

In this prospective cohort study, low SEP was inversely associated with nonelective hospitalizations but not elective hospitalization in older men in Australia. These findings point to the existence of socioeconomic inequalities in health care use, indicative of a need to take action to reduce these inequalities.

The Double Burden of the COVID-19 Pandemic and Polypharmacy on Geriatric Population - Public Health Implications

COVID-19 pandemic is inducing acute respiratory distress syndrome, multi-organ failure, and eventual death. Respiratory failure is the leading cause of mortality in the elderly population with pre-existing medical conditions. This group is particularly vulnerable to infections due to a declined immune system, comorbidities, geriatric syndrome, and potentially inappropriate polypharmacy. These conditions make the elderly population more susceptible to the harmful effects of medications and the deleterious consequences of infections, including MERS-CoV, SARS-CoV, and SARS-CoV-2. Chronic diseases among elderlies, including respiratory diseases, hypertension, diabetes, and coronary heart diseases, present a significant challenge for healthcare professionals. To comply with the clinical guidelines, the practitioner may prescribe a complex medication regimen that adds up to the burden of pre-existing treatment, potentially inducing adverse drug reactions and leading to harmful side-effects. Consequently, the geriatric population is at increased risk of falls, frailty, and dependence that enhances their susceptibility to morbidity and mortality due to SARS-CoV-2 respiratory syndrome, particularly interstitial pneumonia. The major challenge resides in the detection of infection that may present as atypical manifestations in this age group. Healthy aging can be possible with adequate preventive measures and appropriate medication regimen and follow-up. Adherence to the guidelines and recommendations of WHO, CDC, and other national/regional/international agencies can reduce the risks of SARS-CoV-2 infection. Better training programs are needed to enhance the skill of health care professionals and patient’s caregivers. This review explains the public health implications associated with polypharmacy on the geriatric population with pre-existing co-morbidities during the COVID-19 pandemic.

Quality of Life among Obstetric Fistula Patients at Kitovu Mission Hospital: A Health Facility-Based Cross-Sectional Study in Masaka District, Uganda

Background

Obstetric fistula (OF) remains a silent neglected maternal challenge associated with devastating life consequences. Living with OF presents far-reaching physical, social, psychosocial, and emotional concerns, which negatively impact a woman's quality of life. This study evaluated the quality of life among obstetric fistula patients in Masaka district, Uganda.

Method

A cross-sectional study was conducted among 63 women diagnosed with OF at Kitovu Mission Hospital. Data were collected using a questionnaire, observation, in-depth interviews, and focus group discussions. Data were analyzed at univariate, bivariate, and multivariate levels, where the ordinal logistic regression model was applied. The qualitative data was transcribed and analyzed using qualitative content analysis.

Results

Majority (87%) of the women diagnosed with OF reportedly had a poor quality of life. Bivariate analysis indicated that level of education (P < 0.001), employment status (P < 0.001), energy for everyday life (P < 0.001), capacity to work (P < 0.001), satisfaction with personal relationships (P < 0.001), feelings of loneliness (P < 0.001), negative feelings (P = 0.002), and self-confidence (P < 0.001) were significantly associated with good QoL. Multivariate analysis showed increased odds of good QoL increased among women with self-confidence (OR = 32.320; CI = 2.019–517.467), formal education (OR = 9.9497; CI = 1.075–92.048), women who did not experience difficulties in mobility (OR = 19.144; CI = 0.149–2456.770), and women who were satisfied with their personal relationships (OR = 5.785; CI = 0.447–74.824).

Conclusion

A holistic fistula treatment approach is required that takes into consideration all aspects of life to address the consequences of obstetric fistula to realize improved quality of life among patients.

Prevalence and treatment of neurological and psychiatric disorders among tertiary hospitals in Pakistan; findings and implications

INTRODUCTION

Mental health and neurological disorders are prevalent in Pakistan. However, there are considerable concerns with their management due to issues of access, availability of trained personnel and stigma alongside paucity of such data. Consequently, there is a need to document current treatment approaches starting with tertiary hospitals in Pakistan where patients with more severe mental and neurological disorders are typically treated. Subsequently, use the findings to help direct future policies and initiatives.

METHODS

Multi-centered, cross-sectional, prospective study principally evaluating current medicine usage among patients attending tertiary hospitals in Pakistan with psychiatric and neurological disorders. In addition, possible factors contributing to the prevalence of these disorders in this population to help with future care. All 23 tertiary care hospitals in the ten major Districts in Pakistan were included, which cover 75% of the population.

RESULTS

57,664 patients were evaluated of which 35.3% were females. Both females and males had multiple brain disorders and multiple co-morbidities. Schizophrenia was the most prevalent disorder overall among both females (25.2%) and males (30.4%). A median of six medicines were prescribed per patient, with antipsychotics and antidepressants the most prescribed medicines. Clozapine was the most prescribed medicine in males (12.25%) and females (11.83%) including for psychiatric disorders, with sodium valproate the most prescribed medicine in epilepsy in males (42.44% of all anti-epileptic medicines) as well as females (46.38%). There was a greater prevalence of both disorders among the lower classes. A greater prevalence of schizophrenia was seen in patients abusing alcohol and smokers. The divorce rate was higher among the studied patients and the prevalence of depression was higher among the widowed population.

CONCLUSIONS

There were concerns with the quality of prescribing including the extent of polypharmacy as well as possible overuse of clozapine especially in patients with epilepsy, both of which need addressing.

An Increasing Trend in the Prevalence of Polypharmacy in Sweden: A Nationwide Register-Based Study

Aim

Polypharmacy is becoming a global health problem. The aims of this study were to evaluate the temporal trends in the prevalence of polypharmacy in Sweden and to explore polypharmacy disparities by age, gender, education, and immigration status.

Methods

Polypharmacy and excessive polypharmacy were evaluated using data extracted from the Swedish Prescribed Drug Register between 2006 and 2014. Polypharmacy was defined as being exposed to five or more drugs and excessive polypharmacy was defined as being exposed to 10 or more drugs during 1 month respectively. Average annual percent change (AAPC) was calculated using Joinpoint Statistical Software.

Results

The prevalence of polypharmacy increased from 16.9% in 2006 to 19.0% in 2014 with an AAPC of 1.3; the prevalence of excess polypharmacy increased from 3.8% in 2006 to 5.1% in 2014 with an AAPC of 3.4. The prevalence of polypharmacy and excessive polypharmacy increased dramatically with age and peaked up to 79.6% and 36.4% in individuals aged 90 and above respectively. Females and individuals with lower education level were associated with a higher rate of polypharmacy and excessive polypharmacy. Immigrants from Middle-Eastern countries had the highest rate of polypharmacy and excessive polypharmacy, whereas individuals from Western Europe countries had the lowest rate.

Conclusion

The prevalence of polypharmacy has increased gradually in Sweden during the past decade. Individuals with older age, female sex, or lower education have a higher rate of polypharmacy and excessive polypharmacy. Immigrants from Middle-Eastern countries showed a higher rate of polypharmacy.

Race/Ethnicity, Socioeconomic Status, and Polypharmacy among Older Americans

Background: Very few studies with nationally representative samples have investigated the combined effects of race/ethnicity and socioeconomic position (SEP) on polypharmacy (PP) among older Americans. For instance, we do not know if prevalence of PP differs between African Americans (AA) and white older adults, whether this difference is due to a racial gap in SEP, or whether racial and ethnic differences exist in the effects of SEP indicators on PP. Aims: We investigated joint effects of race/ethnicity and SEP on PP in a national household sample of American older adults. Methods: The first wave of the University of Michigan National Poll on Healthy Aging included a total of 906 older adults who were 65 years or older (80 AA and 826 white). Race/ethnicity, SEP (income, education attainment, marital status, and employment), age, gender, and PP (using 5+ medications) were measured. Logistic regression was applied for data analysis. Results: Race/ethnicity, age, marital status, and employment did not correlate with PP; however, female gender, low education attainment, and low income were associated with higher odds of PP among participants. Race/ethnicity interacted with low income on odds of PP, suggesting that low income might be more strongly associated with PP in AA than white older adults. Conclusions: While SEP indicators influence the risk of PP, such effects may not be identical across diverse racial and ethnic groups. That is, race/ethnicity and SEP have combined/interdependent rather than separate/independent effects on PP. Low-income AA older adults particularly need to be evaluated for PP. Given that race and SEP have intertwined effects on PP, racially and ethnically tailored interventions that address PP among low-income AA older adults may be superior to universal interventions and programs that ignore the specific needs of diverse populations. The results are preliminary and require replication in larger sample sizes, with PP measured directly without relying on individuals’ self-reports, and with joint data collected on chronic disease.

Polypharmacy and Psychological Distress May Be Associated in African American Adults

Background: Compared to Whites, African Americans are at a higher risk of multiple chronic conditions, which places them at a higher risk of polypharmacy. Few national studies, however, have tested whether polypharmacy is associated with psychological distress—the net of socioeconomic status, health status, and stress—in African Americans. Aims: In a national sample of African Americans in the US, this study investigated the association between polypharmacy and psychological distress. Methods: The National Survey of American Life (NSAL, 2003) included 3570 African American adults who were 18 years or over. This number was composed of 2299 women and 1271 men. Polypharmacy (using ≥ 5 medications) and hyper-polypharmacy (using ≥ 10 medications) were the independent variables. Psychological distress was the dependent variable. Age, gender, socioeconomic status (education attainment, income, employment, and marital status), health care access (insurance status and usual place of care), and health status (multimorbidity and psychiatric disorders) were the covariates. Linear multivariable regression was applied to perform the data analysis. Results: Both polypharmacy and hyper-polypharmacy were associated with psychological distress. This association was significant after controlling for all the covariates. Conclusions: African Americans with polypharmacy, particularly those with hyper-polypharmacy, are experiencing higher levels of psychological distress, which itself is a known risk factor for poor adherence to medications. There is a need for a comprehensive evaluation of medications as well as screening for psychopathology in African Americans with multiple medical conditions.