Polypharmacy in Assisted Living and Impact on Clinical Outcomes

Assisted living or nursing home: Who is moving in?

BACKGROUND

Despite the rapid growth of assisted living (AL) communities and the increasing similarity between AL and nursing home (NH) populations, little is known about the characteristics of older adults at the time of AL admission and how these characteristics compare to individuals newly admitted to NH from the community. This study examined the individual, facility, and geographic factors associated with new AL admission.

METHODS

This retrospective descriptive study used data from the national Medicare enrollment and claims datasets, the Minimum Data Set, and the Medicare Provider Analysis and Review. The study cohort included 158,124 Medicare beneficiaries newly admitted to ALs and 715,261 newly admitted to NHs during 10/2017-10/2019. Multinomial logistic regression analysis and logistic regression analysis were conducted to examine factors associated with new admissions.

RESULTS

Demographic, socioeconomic, and health service use characteristics were associated with new admission to long-term care. Specifically, Medicare fee-for-service beneficiaries, those age 75 years and older, male, having one skilled nursing facility (SNF) stay or any hospital stay in the past 6 months are more likely to be newly admitted to AL, whereas those who are dually eligible, racial/ethnic minorities, and having two or more SNF stays in the past 6 months are more likely to be admitted to an NH.

CONCLUSION

There are substantial differences between individuals who are newly admitted from the community to AL versus those to NH.

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

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

Polypharmacy and associated factors: a gender perspective in the elderly Spanish population (2011-2020)

Background: Few studies have examined the epidemiology of polypharmacy in non-institutionalized elderly adults with regard to sex differences. This study aimed to identify the prevalence of polypharmacy among people ≥65 years old residing in Spain, analyze trends in that prevalence from 2011/12 to 2020, describe the use of the medicines involved and study the possible relationship between polypharmacy and certain sociodemographic, health-related variables, as well as the use of care services by sex. Methods: A nationwide cross-sectional study with 21,841 non-institutionalized people ≥65 years old from the Spanish National Health Survey (2011/2012 and 2017) and the European Health Survey in Spain (2014 and 2020) was performed. We used descriptive statistics, performing two binary logistic regressions to determine the factors related to polypharmacy. Results: The prevalence of polypharmacy was 23.2% (women: 28.1%, men: 17.2%; p < 0.001). The most commonly consumed medicines were analgesics and tranquillizers, relaxants or sleeping pills in elderly women, compared with antihypertensives, antacids and antiulcer drugs and statins for elderly men. In both sexs, the positive predictors of polypharmacy included average, poor and very poor self-perceived states of health, people with overweight and obesity, being severely/non-severely limited due to a health problem, having ≥ three chronic conditions, visits to the family doctor and hospitalization. Among elderly women, negative predictors were alcohol intake, whereas in elderly men positive predictors were being 75-84 years old, being current smokers and having 1, 2 chronic conditions. Conclusion: Polypharmacy has a prevalence of 23.2%, with women accounting for 28.1% and men 17.2% of the total. Knowledge of positive and negative predictors of polypharmacy have important implications for public health efforts to develop or improve health guidelines and strategies for promoting the proper use of medication, particularly in the elderly population by sex.

Controversies in Osteoporosis Treatment of Nursing Home Residents

Osteoporotic fractures are a common and serious health problem for older adults living in nursing homes (NHs). Risk of fracture increases with age and dementia status, yet gaps in evidence result in controversies around when to start and stop treatment for osteoporosis in NH residents, particularly those who have high fracture risk but have limited life expectancy. In this article, we discuss these areas of controversy. We provide an overview of current guidelines that explicitly address osteoporosis treatment strategies for NH residents, review the evidence for osteoporosis medications in NH residents, and use these sources to suggest practical recommendations for clinical practice and for research. Three published guidelines (from the United States, Canada, and Australia) and several studies provide the current basis for clinical decisions about osteoporosis treatment for NH residents. Practical approaches may include broad use of vitamin D and selective use of osteoporosis medication based on risks, benefits, and goals of care. Clinicians still lack strong evidence to guide treatment of NH residents with advanced dementia, multimorbidity, or severe mobility impairment. Future priorities for research include identifying optimal approaches to risk stratification and prevention strategies for NH residents and evaluating the risk-benefit profile of pharmacologic treatments for osteoporosis NH residents across key clinical strata. In the absence of such evidence, decisions for initiating and continuing treatment should reflect a patient-centered approach that incorporates life expectancy, goals of care, and the potential burden of treatment.

Potentially Inappropriate Medication Use among Nursing Home Residents: Medication Errors Associated with Pro re nata Medications and the Importance of Pill Burden

Background

The use of potentially inappropriate medications (PIM) has become more common among nursing home residents (NHR). This study focused on drugs initially prescribed as pro re nata (PRN) medications and pill burden in association with PIM among NHR.

Methods

This observational cross-sectional study was conducted between March and April 2019 on 225 adult NHR aged ≥60 years.

Results

The prevalence of PIM was 47.6% among NHR according to the Screening Tool of Older Persons' Prescriptions (STOPP) criteria version 2. The most frequent PIM was the use of any drug prescribed without evidence-based clinical indication; most medication errors were associated with PRN medications. The prevalence rates of PRN in non-PIM and PIM users were 12% and 62.4%, respectively. PRN medications that most commonly caused PIM were non-steroidal anti-inflammatory drugs and proton pump inhibitors. The cut-off value for both medications and pills to correctly identify participants with PIM was 5.5. Pill burden had a similar sensitivity to polypharmacy in identifying individuals with PIM.

Conclusion

Medication errors associated with PRN medications were overlooked as factors that increased the risk of PIMs. The most common error related to PRN medications was the continued daily use despite symptom resolution.

Neglecting the care of older people in residential care settings: A national document analysis of complaints reported to the Finnish supervisory authority

Neglecting to provide older people with the care they need in residential care settings leads to human suffering and increased service needs. Research is lacking on neglect in older people's residential care and one way to assess the key issues is to study complaints. The aim of this study was to analyse official complaints related to allegations of neglect in residential care settings caring for older people in Finland. The data covered 317 complaints that were recorded in the national database in 2018 and 2019. The analysis of the complaints yielded 2,922 observations of neglect in older people's care in residential care settings. Based on our results, most of the complaints were made by family members when the patients were alive and their motivation was to improve the care their relative received, as well as the care of others, in the residential care home. The complaints focused on neglecting clinical care, including restricting older people's movements, not providing daily activities and not paying sufficient attention to their hygiene and secretions. Other complaints included issues relating to nutrition, medication, communication and issues that compromised their privacy, respect and dignity. Nearly three of four complaints identified staffing issues in relation to neglect and most of the complaints concerned private, rather than public, residential care homes. Although the complaints only concerned a small proportion of the annual care provided, more attention should be paid to care practices that prevent neglect in residential care and to multi-level monitoring for dignified care.

Potentially Inappropriate Medication among Older Patients Who Are Frequent Users of Outpatient Services

Aging is accompanied by changes in organ degeneration, and susceptibility to multiple diseases, leading to the frequent occurrence of adverse drug reactions resulting from polypharmacy (PP) and potentially inappropriate medications (PIM) in older patients. This study employs a retrospective cohort design and investigates the association of PP with PIM among older patients with high rates of medical utilization. Using records from a national pharmaceutical care database, an experimental group is formed from patients meeting these criteria, who are then offered home pharmaceutical care. Correspondingly, a control group is formed by identifying older patients with regular levels of use of medical services who had been dispensed medications at community pharmacies. Multivariate logistic regression is performed to assess the association between the rate of PIM and variables, including age, gender, and PP. The study finds that experimental PP participants had a higher rate of PIM prescription (odds ratio (OR) = 5.4) than non-PP control participants (all p < 0.001). In clinical practice, additional caution is required to avoid PIMs. Patients engaged in continuously using long-term medication should take precautions in daily life to alleviate related discomforts. Pharmacists should serve as a bridge between patients and physicians to enhance their health and improve their quality of life.

Developing and Testing A Model of the Assisted Living Environment

The assisted living (AL) environment plays an important role in supporting residents' satisfaction and helping them to age in place. The AL environment is multidimensional and has many interrelated components including staffing (e.g. direct care workers, nursing, activity staff), services provided (e.g. medical, mental health, pharmacy), amenities offered at the setting (e.g. beauty salon, library, exercise facilities), and the physical environment. Evidence suggests that aspects of the AL environment can enhance or detract from the physical function, well-being, social engagement, and behavioral outcomes among residents. The purpose of this study was to develop and test a multidimensional AL environment measurement model that includes indicators of staffing, services, amenities, and the physical environment. Baseline data was used from a study testing the Dissemination and Implementation of Function Focused Care in AL. A total of 54 AL facilities across three states were included in the sample. Settings ranged in size from 31 to 164 beds with an average size of 82.2 (SD=26.2) beds and the majority were for profit facilities (n=41, 74.5%). Structural equation modeling was used to test the proposed model. Results showed that the model fit the data (χ2/df=1.861, p<.05; CFI=.858, RMSEA=.126). Having a comprehensive AL environment measurement model will advance future research that explores the impact of the environment on resident outcomes. Findings from this study will inform interventions and programs designed to modify AL environments to optimize residents' satisfaction with AL.

Physical Activity and Function in Assisted Living Residents

The purpose of this study was to consider the feasibility, reliability, and validity of MotionWatch 8. A total of 249 residents were recruited from 26 assisted living settings. Data collection included demographics, comorbidities, function (Barthel Index), physical activity (MotionWatch 8), and falls. The mean age of participants was 86.86 ( SD = 7.0), the majority were women 179 (74%) and White ( N = 232, 96%). A total of 86% of participants wore the MotionWatch 8. There were no significant differences in physical activity over 3 days of testing. The MotionWatch 8 findings were significantly associated with activities of daily living (ADL) function. There were no significant differences in ADL function or physical activity between those who did and did not fall. The study provides additional support for the feasibility, reliability, and validity of the MotionWatch 8 and confirms that older adults living in assisted living settings spend the majority of their time in sedentary activity.