Medications and Prescribing Patterns as Factors Associated with Hospitalizations from Long-Term Care Facilities: A Systematic Review

The influence of patients' beliefs about medicines and the relationship with suboptimal medicine use in community-dwelling older adults: a systematic review of quantitative studies

BACKGROUND

Medication use in older adults is increasing, therefore, reducing the risk of suboptimal medicine use is imperative in achieving optimal therapeutic outcomes. Research suggests that factors such as personal beliefs and beliefs about medicines may be associated with non-adherence and inappropriate medicine use.

AIM

To systematically review and identify quantitative research on the influence of beliefs about medicines and the relationship with suboptimal medicine use in older adults.

METHOD

Searches were conducted on PubMed, EMBASE, CINAHL, and PsycINFO for quantitative studies (inception to March 2023).

INCLUSION CRITERIA

(1) exposure: participants' beliefs (personal, cultural, and medication-related), (2) outcomes: polypharmacy, potentially inappropriate medicines use, or non-adherence, and (3) participants: community-dwelling adults 65 years or above. Study selection, data extraction and quality appraisal (Joanna Briggs Institute critical appraisal checklist) were completed independently by two investigators. Data were combined in a narrative synthesis and presented in a summary of findings table.

RESULTS

Nineteen articles were included: 15 cross-sectional and four cohort studies. Outcomes of included papers were as follows; adherence (n = 18) and potentially inappropriate medicine use (n = 1). Ten studies found stronger beliefs in the necessity of medicines and/or fewer concerns led to better adherence, with one paper contradicting these findings. Three studies did not find associations between adherence and beliefs. One study confirmed an association between unnecessary drug use and a lack of belief in a "powerful other" (e.g. doctor).

CONCLUSION

Further investigation is necessary to (1) ascertain the importance of necessity or concern beliefs in fostering adherence and, (2) examine the influence of beliefs on polypharmacy and inappropriate medicine use.

Development of a list of Australian potentially inappropriate medicines using the Delphi technique

BACKGROUND

Older people are at high risk of medicines-related harms. otentially inappropriate medicines (PIMs) list has been developed to assist clinicians and researchers to identify medicines with risks that may potentially outweigh their benefits in order to improve medication management and safety.

AIM

To develop a list of PIMs for older people specific to Australia.

METHODS

The study obtained expert consensus through the utilisation of the Delphi technique in Australia. A total of 33 experts partook in the initial round, while 32 experts engaged in the subsequent round. The primary outcomes encompass medicines assessed as potentially inappropriate, the specific contexts in which their inappropriateness arises and potentially safer alternatives.

RESULTS

A total of 16 medicines or medicine classes had one or more medicines deemed as potentially inappropriate in older people. Up to 19 medicines or medicine classes had specific conditions that make them more potentially inappropriate, while alternatives were suggested for 16 medicines or classes.

CONCLUSION

An explicit PIMs list for older people living in Australia has been developed containing 19 drugs/drug classes. The PIMs list is intended to be used as a guide for clinicians when assessing medication appropriateness in older people in Australian clinical settings and does not substitute individualised treatment advice from clinicians.

Co-existence of malnutrition and sarcopenia and its related factors in a long-term nursing care facility: A cross-sectional study

Objectives

Malnutrition and sarcopenia often co-exist in older patients. This condition, called co-MS, shows a worse prognosis than either condition alone but is often overlooked and undertreated. We aimed to clarify the prevalence of co-MS and its associated factors with a focus on prescription in a long-term nursing care facility in Japan.

Methods

Patients aged >65 years who resided in a long-term nursing care facility in Hyogo, Japan, were recruited for this cross-sectional study, which was conducted from July 1 to July 30, 2022. Sarcopenia and malnutrition were diagnosed using the Asian Working Group for Sarcopenia and Global Leadership Initiative on Malnutrition criteria, respectively. Patients who met both criteria were classified as having co-MS. Potentially associated factors, including age, sex, length of stay, activities of daily living, comorbidity, oral function and hygiene, swallowing ability, and the number and type of prescriptions, were assessed.

Results

The prevalence of sarcopenia was 92 % (72/78). All malnourished patients were sarcopenic (40.3 %) and were classified as having co-MS. Oral function and hygiene, swallowing ability, comorbidity, and the presence of potentially inappropriate medications showed significant associations in univariate analyses. Of particular note, potentially inappropriate medication was an independent factor in the multivariate analysis.

Conclusions

Co-MS is prevalent in long-term nursing care facilities; thus, healthcare workers should pay attention to relevant factors to identify patients at risk of co-MS and to provide appropriate care and intervention.

What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews

BACKGROUND

care home residents aged over 65 have disproportionate rates of emergency department (ED) attendance and hospitalisation. Around 40% attendances may be avoidable, and hospitalisation is associated with harms. We synthesised the evidence available in qualitative systematic reviews of different stakeholders' experiences of decisions to transfer residents to the ED.

METHODS

six electronic databases, references and citations of included reviews and relevant policy documents were searched. Reviews of qualitative studies exploring factors that influenced care home staff, medical practitioners, residents' family or residents' experiences and factors influencing decisions to transfer residents to the ED were included. Thematic analysis was used to synthesise findings.

RESULTS

six previous reviews were included, which synthesised the findings of 34 primary studies encompassing 152 care home residents, 283 resident family members or carers and 447 care home staff. Of the primary studies, 19 were conducted in the North America, seven in Australia, five were conducted in Scandinavia, two in the United Kingdom and one in Holland. Three themes were identified: (i) power dynamics between residents, family members, care home staff and health care professionals (external to the care home) influence decisions; (ii) admission can be necessary; however, (iii) some decisions may be driven by factors other than clinical need.

CONCLUSION

transfer decisions are complex and are determined not just by changes in health status interventions aimed at reducing avoidable transfers need to address the key role family members have in transfer decisions, the medical legal fears of care home staff and barriers to accessing community services.

Exploring the implementation of an outreach specialist program for nursing home residents in Macao: A multisite, qualitative study

Background

The "Specialist Medical Outreach Project (SMOP)" involving inter-disciplinary hospital-based healthcare professionals is a government initiative that aims to provide integrative specialist care to high-risk residents at the nursing homes. However, research exploring the implementation and impact of SMOP is lacking. This study aimed to evidence the impact of SMOP on the quality of care at the nursing home and the key contextual determinants influencing SMOP outcomes.

Method

Semi-structured key informant audio-recorded face-to-face interviews were conducted with eight managers, six doctors, 28 nursing staff, and seven pharmacy staff at the nursing homes participating in the SMOP to collect insights about how SMOP was operated and performed, and the impact of SMOP as observed and expected. Participants were recruited with purposive sampling. A thematic analysis approach was employed and key themes were identified using open coding, grouping, and categorizing.

Results

Forty-nine interviews were conducted. Thematic analysis identified three principal themes: the overall perception about SMOP, the benefits as observed; and the areas of improvement. Together with the 10 subthemes, the results highlighted the expectations for SMOP to address the unmet needs and promote patient-centered care, and the benefits of SMOP in supporting effective use of resources for the nursing home, reducing the risks of adverse events for the residents, promoting communication and capacity building for the healthcare providers and facilitating efficient use of healthcare resources for the health system. Requests for more frequent visits by a larger inter-disciplinary specialist team were raised. Careful staff and workflow planning, and mechanisms for data-sharing and communication across care settings were deemed the most important actions for improvement.

Conclusion

It is a general perception that the SMOP is beneficial in enhancing the quality of care for high-risk residents in the nursing home in Macao. Cross-sector inter-disciplinary collaboration and efficient data-sharing and communication mechanism play a crucial role in ensuring the success of the program. A robust assessment framework to monitor and evaluate the cost-effectiveness of the program is yet to be developed.

Factors associated with increased Emergency Department transfer in older long-term care residents: a systematic review

The proportion of adults older than 65 years is rapidly increasing. Care home residents in this age group have disproportionate rates of transfer to the Emergency Department (ED) and around 40% of attendances might be avoidable. We did a systematic review to identify factors that predict ED transfer from care homes. Six electronic databases were searched. Observational studies that provided estimates of association between ED attendance and variables at a resident or care home level were included. 26 primary studies met the inclusion criteria. Seven common domains of factors assessed for association with ED transfer were identified and within these domains, male sex, age, presence of specific comorbidities, polypharmacy, rural location, and care home quality rating were associated with likelihood of ED transfer. The identification of these factors provides useful information for policy makers and researchers intending to either develop interventions to reduce hospitalisations or use adjusted rates of hospitalisation as a care home quality indicator.

[Emergency situations and emergency department visits in nursing homes-a scoping review about circumstances and healthcare interventions]

BACKGROUND

Nursing home residents are more likely to be hospitalized as non-institutionalized peers. A large number of emergency medical services (EMS) and emergency department visits are classified as potentially avoidable.

OBJECTIVES

To identify circumstances that increase the number of emergency situations in nursing homes and approaches to reduce hospital admissions in order to illustrate the complexity and opportunities for action.

MATERIALS AND METHODS

Scoping review with analysis of current original and peer-reviewed papers (2015-2020) in PubMed, CINAHL, and hand-search databases.

RESULTS

From 2486 identified studies, 302 studies were included. Injuries, fractures, cardiovascular, respiratory, and infectious diseases are the most frequent diagnostic groups that have been retrospectively recorded. Different aspects could be identified as circumstances inducing emergency department visits: resident-related (e.g., multimorbidity, lack of volition, and advance directives), facility-related (e.g., staff turnover, uncertainties), physician-related (lack of accessibility, challenging access to specialists), and system-related circumstances (e.g., limited possibilities for diagnostics and treatment in facilities). Multiple approaches to reduce emergency department visits are being explored.

CONCLUSIONS

A variety of circumstances influence the course of action in emergency situations in nursing facilities. Therefore, interventions to reduce emergency department visits address, among other things, strengthening the competence of nursing staff, interprofessional communication, and systemic approaches. A comprehensive understanding of the complex processes of care is essential for developing and implementing effective interventions.

Experience and Appreciation of Health Care Teams Regarding a New Model of Pharmaceutical Care in Long-Term Care Settings

In long-term care (LTC) homes, the management of frail older residents’ pharmacotherapy may be challenging for health care teams. A new pharmaceutical care model highlighting the recently expanded scope of pharmacists’ practice in Quebec, Canada, was implemented in two LTC homes. This study aimed to evaluate health care providers’ experience and satisfaction with this new practice model. Twenty-three semi-structured interviews were performed and analyzed thematically. Positive results of the model have been identified, such as increased timeliness of interventions. Barriers were encountered, such as lack of clarity regarding roles, and suboptimal communication. The increased involvement of pharmacists was perceived as useful in the context of scarce medical resources. Although requiring time and adjustments from health care teams, the new model seems to contribute to the health care providers’ work satisfaction and to positively influence the timeliness and quality of care offered to LTC residents.

Applicability of explicit potentially inappropriate medication lists to the Australian context: A systematic review

OBJECTIVES

To determine i) the similarity of potentially inappropriate medications specified in and between existing explicit lists and ii) the availability in Australia of medications included on existing lists to determine their applicability to the Australian context.

METHODS

This systematic review identified explicit potentially inappropriate medication lists that were published on EMBASE (1974 - April 2021), MEDLINE (1946 - April 2021) and Elsevier Scopus (2004 - April 2021). The reference lists of seven previously published systematic reviews were also manually reviewed. Lists were included if they were explicit, and the most recent version and the complete list were published in English. Lists based on existing lists were excluded if no new items were added. Potentially inappropriate medications identified on each list were extracted and compared to the medications available on the Australian Register of Therapeutic Goods and Australian Pharmaceutical Benefits Schemes.

RESULTS

Thirty-five explicit published lists were identified. A total of 645 unique potentially inappropriate medications were extracted, of which 416 (64%) were available in Australia and 262 (41%) were subsided by the general Pharmaceutical Benefits Scheme. Applicability of each explicit list ranged from 50-96% according to medications available in Australia and 25-83% according to medications available under subsidy.

CONCLUSIONS

Pooling data from different lists may help to identify potentially inappropriate medications that may be applicable to local settings. However, if selecting a list for use in the Australian context, consideration should also be given to the intended purpose and setting for application.

Potentially inappropriate medication prescribing among elderly patients with cardiovascular diseases

Background/Aim. The growing number of older adults means higher medicine utilization. The aim of the study was to determine the frequency and identify risk factors of potentially inappropriate medication (PIM) in the elderly population with cardiovascular diseases. Methods. The retrospective, cross-sectional study was performed in 2018, and the relevant data were collected during the period from January 2016 to December 2017. The study sample included 1,500 patients over 65 years with cardiovascular disease who had medical records at the Institute for Gerontology and Palliative Care, Belgrade. Assessment of PIM was done by standard international criteria such as the American Geriatrics Society 2015 updated Beers Criteria for PIM use in older adults. Results. PIM frequency in the elderly population was 70.3%. In relation to gender, it was more frequent in female elders. The mean number of prescribed drugs was similar for 2016 and 2017, 7.2 and 7.3, respectively. The most common were: medium-acting benzodiazepines (70.9%), central ? blockers (23.98%), and antipsychotics (typical and atypical) (20.94%). The most common comorbidity was noted in a group labeled with the International Disease Classification I00-I99, which includes heart and blood vessel diseases [n = 2,658 (36.9%)]. The most common diagnoses belonged to the subgroups I10-I15 [hypertensive diseases, n = 1,298 (18%)], I20-I25 [ischemic heart diseases n = 542 (7.5%)], I30-I52 [other forms of heart disease, n = 705 (9.8%)], I60-I69 [cerebrovascular diseases, n = 94 (1.3%)], and I80- I89 [diseases of veins, lymph vessels, and lymph nodes n = 12 (0.17%)]. The risk factors for PIM were: polypharmacy, gender, nicotine use, cognitive status, nutrition state, and the number of diseases registered in the study sample. Conclusion. Cardiovascular diseases in the elderly population are associated with a high prevalence of PIM. Creating health recommendations for prescribing drugs to the elderly that would emphasize these factors could reduce the prevalence of PIM in this population.

Anticholinergics and clinical outcomes amongst people with pre-existing dementia: A systematic review

Many medicines have anticholinergic properties, which have previously been correlated with a range of adverse effects, including cognitive impairment, hallucinations and delirium. These effects are potentially of concern for people with dementia. This systematic review investigated the effect of anticholinergic medicines on the health outcomes of people with pre-existing dementia. Embase, Medline and the Cochrane Library were searched from January 2000 to January 2021. Studies were included if they matched the following criteria: (1) the intervention involved anticholinergic medications; (2) the study was conducted in people with pre-existing dementia; (3) there was at least one comparator group; and (4) the outcome of interest was clinically measurable. A total of 14 studies met the inclusion criteria. Most studies used an anticholinergic burden scale to measure anticholinergic exposure. Five high-quality studies consistently identified a strong association between anticholinergic medications and all-cause mortality. Anticholinergics were also found to be associated with longer hospital length of stay in three studies. Inconsistent findings were reported for cognitive function (in 4 studies) and neuropsychiatric functions (in 2 studies). In single studies, anticholinergic medications were associated with the composite outcome of stroke and mortality, pneumonia, delirium, poor physical performance, reduced health-related quality of life and treatment modifications due to reduced treatment response or symptom exacerbation. While the evidence suggests that anticholinergic medication use for people with dementia has a strong association with all-cause mortality, the association with cognitive and other clinical outcomes remains uncertain. Hence, further studies are needed to substantiate the evidence for other outcomes.

Reduction in unplanned hospitalizations associated with a physician focused intervention to reduce potentially inappropriate medication use among older adults: a population-based cohort study

Background

A multimodal general practitioner-focused intervention in the Local Health Authority (LHA) of Parma, Italy, substantially reduced the prevalence of potentially inappropriate medication (PIM) use among older adults. Our objective was to estimate changes in hospitalization rates associated with the Parma LHA quality improvement initiative that reduced PIM use.

Methods

This population-based longitudinal cohort study was conducted among older residents (> 65 years) using the Parma LHA administrative healthcare database. Crude and adjusted unplanned hospitalization rates were estimated in 3 periods (pre-intervention: 2005–2008, intervention: 2009–2010, post-intervention: 2011–2014). Multivariable negative binomial models estimated trends in quarterly hospitalization rates among individuals at risk during each period using a piecewise linear spline for time, adjusted for time-dependent and time-fixed covariates.

Results

The pre-intervention, intervention, and post-intervention periods included 117,061, 107,347, and 121,871 older adults and had crude hospitalization rates of 146.2 (95% CI: 142.2–150.3), 146.8 (95% CI: 143.6–150.0), and 140.8 (95% CI: 136.9–144.7) per 1000 persons per year, respectively. The adjusted pre-intervention hospitalization rate was declining by 0.7% per quarter (IRR = 0.993; 95% CI: 0.991–0.995). The hospitalization rate declined more than twice as fast during the intervention period (1.8% per quarter, IRR = 0.982; 95% CI: 0.979–0.985) and was nearly constant post-intervention (IRR: 0.999; 95% CI: 0.997–1.001). Contrasting model predictions for the intervention period (Q1 2009 to Q4 2010), the intervention was associated with 1481 avoided hospitalizations.

Conclusion

In a large population of older adults, a multimodal general practitioner-focused intervention to decrease PIM use was associated with a decline in the unplanned hospitalization rate. Such interventions to reduce high risk medication use among older adults warrant consideration by health systems seeking to improve health outcomes and reduce high-cost acute care utilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02172-3.

Is polypharmacy beneficial or detrimental for older adults with cardiometabolic multimorbidity? Pooled analysis of studies from Hong Kong and Europe

BACKGROUND

Physicians often prescribe high numbers of medications for managing multiple cardiometabolic diseases. It is questionable whether polypharmacy (concurrent use of five or more medications) is beneficial or detrimental for older adults with cardiometabolic multimorbidity (co-occurrence of two or more diseases).

OBJECTIVE

To examine combined effects of multimorbidity and polypharmacy on hospitalization and frailty and to determine whether effect sizes of polypharmacy vary with numbers of cardiometabolic diseases.

METHODS

We pooled longitudinal data of community-dwelling older adults in Hong Kong, Israel, and 17 European countries. They completed questionnaires for baseline assessment from 2015 to 2018 and reassessment at 1-2-year follow-up. We performed regression analyses to address the objective.

RESULTS

Among 44 818 participants (mean age: 69.6 years), 28.3% had polypharmacy and 34.8% suffered from cardiometabolic multimorbidity. Increased risks of hospitalization and worsening frailty were found in participants with 'multimorbidity alone' [adjusted odds ratio (AOR) 1.10 and 1.26] and 'polypharmacy alone' (AOR 1.57 and 1.68). With 'multimorbidity and 'polypharmacy' combined, participants were not at additive risks (AOR 1.53 and 1.47). In stratified analysis, with increasing numbers of cardiometabolic diseases, associations of polypharmacy with hospitalization and frailty were attenuated but remained statistically significant.

CONCLUSION

Polypharmacy is less detrimental, yet still detrimental, for older adults living with cardiometabolic multimorbidity. Physicians should optimize prescription regardless of the number of diseases. Health policymakers and researchers need to consider their interrelationship in hospitalization risk predictions and in developing frailty scales.

Improving accessibility of the Australian My Health Records while preserving privacy and security of the system

Australian My Health Record (MyHR) is a significant development in empowering patients, allowing them to access their summarised health information themselves and to share the information with all health care providers involved in their care. Consequently, the MyHR system must enable efficient availability of meaningful, accurate, and complete data to assist an improved clinical administration of a patient. However, while enabling this, protecting data privacy and ensuring security in the MyHR system has become a major concern because of its consequences in promoting high standards of patient care. In this paper, we review and address the impact of data security and privacy on the use of the MyHR system and its associated issues. We determine and analyse where privacy becomes an issue of using the MyHR system. Finally, we also present an appropriate method to protect the security and privacy of the MyHR system in Australia.

A nurse practitioner led protocol to address polypharmacy in long-term care

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Polypharmacy is common in long term care facilities and frequently associated with poor outcomes.

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A focus on decreasing polypharmacy as part of 60-day periodic review process in long term care facilities has the potential to improve resident outcomes and assist health care providers in improved medication management.

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To achieve success in decreasing polypharmacy, an interdisciplinary team with shared goals and communication is needed.

Polypharmacy is common in long term care facilities and frequently associated with poor outcomes. This study sought to determine if a medication management protocol completed at four month intervals by nurse practitioners (NP) could impact polypharmacy and administration times for long term care residents. The data was collected as part of a Centers for Medicare and Medicaid Services (CMS) “Initiative to Reduce Avoidable Hospitalization among Nursing Facility Residents” grant. Residents were recruited from participating long-term care facilities. NP completed a medication management protocol on admission to the program and at subsequent 4-month intervals or with an acute change in condition. A total of 2442 non-duplicated individuals were seen for at least 1 visit. Although the protocol did not result in a reduction of regularly scheduled medications, the number of scheduled medication administration times did significantly decrease. NP polypharmacy assessments and recommendations are important but were insufficient to decrease the medication burden.

Characterization and Evolutionary Analysis of a Novel H3N2 Influenza A Virus Glycosylation Motif in Southern China

An influenza A (H3N2) virus epidemic occurred in China in 2017 and the causative strain failed to bind red blood cells (RBCs), which may affect receptor binding and antibody recognition. The objective of this study was to analyze the genetic characteristics and glycosylation changes of this novel H3N2 strain. We directly sequenced the hemagglutinin (HA) genes of H3N2 clinical specimens collected from patients with acute respiratory tract infection during 2017 in Guangdong, China. We aligned these sequences with those of A/Hong Kong/1/1968 (H3N2) and A/Brisbane/10/2007 (H3N2). Glycosylation changes were analyzed by C18 Chip-Q-TOF-MS. A/China/LZP/2017 (H3N2) was negative by HA assay, but was positive by quantitative real-time Polymerase Chain Reaction (qPCR) and direct immunofluorescence assay (DFA). We found that the HA1 residue 160T of A/China/LZP/2017 (H3N2) could block virus binding to receptors on RBCs. Furthermore, the ASN (N)-X-Thr (T) motif at HA1 residues 158-160, encoding a glycosylation site as shown by C18 Chip-Q-TOF-MS, predominated worldwide and played a critical role in RBC receptor binding. Ten glycoforms at HA1 residue 158 were identified [4_3_1_0, 5_6_0_1, 3_3_0_1, 4_4_3_0, 6_7_0_0 (SO3), 3_6_2_0, 4_3_1_2 (SO3), 7_5_2_0 (SO3), 3_6_2_1 (SO3), and 3_7_0_2]. Glycosylation changes at HA1 residues 158-160 of a circulating influenza A (H3N2) virus in Guangdong, China, in 2017 blocked binding to RBC receptors. Changes to these HA1 residues may have reduced protective antibody responses as well. Understanding these critical epitopes is important for selecting vaccine strains.

Do Centenarians Die Healthier than Younger Elders? A Comparative Epidemiological Study in Spain

This study aims to describe the clinical course, drug use, and health services use characteristics during the last year of life of elders who die being centenarians and to identify key aspects differentiating them from elders who die at an earlier age, with a particular focus on sex differences. We conducted an observational, population-based study in the EpiChron Cohort (Aragón, Spain). The population was stratified by sex and into three age sub-populations (80-89, 90-99, and ≥100 years), and their characteristics were described and compared. Multimorbidity was the rule in our elders, affecting up to 3 in 4 centenarians and 9 in 10 octogenarians and nonagenarians. Polypharmacy was also observed in half of the centenarian population and in most of the younger elders. Risk factors for cardiovascular disease (i.e., hypertension, dyslipidaemia, diabetes), cerebrovascular disease and dementia were amongst the most common chronic conditions in all age groups, whereas the gastroprotective drugs and antithrombotic agents were the most dispensed drugs. Centenarians presented in general lower morbidity and treatment burden and lower use of both primary and hospital healthcare services than octogenarians and nonagenarians, suggesting a better health status. Sex-differences in their clinical characteristics were more striking in octogenarians and tended to decrease with age.

Root Cause Analysis to Identify Medication and Non-Medication Strategies to Prevent Infection-Related Hospitalizations from Australian Residential Aged Care Services

Infections are leading causes of hospitalizations from residential aged care services (RACS), which provide supported accommodation for people with care needs that can no longer be met at home. Preventing infections and early and effective management are important to avoid unnecessary hospital transfers, particularly in the Australian setting where new quality standards require RACS to minimize infection-related risks. The objective of this study was to examine root causes of infection-related hospitalizations from RACS and identify strategies to limit infections and avoid unnecessary hospitalizations. An aggregate root cause analysis (RCA) was undertaken using a structured local framework. A clinical nurse auditor and clinical pharmacist undertook a comprehensive review of 49 consecutive infection-related hospitalizations from 6 RACS. Data were collected from nursing progress notes, medical records, medication charts, hospital summaries, and incident reports using a purpose-built collection tool. The research team then utilized a structured classification system to guide the identification of root causes of hospital transfers. A multidisciplinary clinical panel assessed the root causes and formulated strategies to limit infections and hospitalizations. Overall, 59.2% of hospitalizations were for respiratory, 28.6% for urinary, and 10.2% for skin infections. Potential root causes of infections included medications that may increase infection risk and resident vaccination status. Potential contributors to hospital transfers included possible suboptimal selection of empirical antimicrobial therapy, inability of RACS staff to establish on-site intravenous access for antimicrobial administration, and the need to access subsidized medical services not provided in the RACS (e.g., radiology and pathology). Strategies identified by the panel included medication review, targeted bundles of care, additional antimicrobial stewardship initiatives, earlier identification of infection, and models of care that facilitate timely access to medical services. The RCA and clinical panel findings provide a roadmap to assist targeting services to prevent infection and limit unnecessary hospital transfers from RACS.

A Practical Approach to Using Adjuvant Analgesics in Older Adults

The adjuvant analgesics are a large and diverse group of drugs that were developed for primary indications other than pain and are potentially useful analgesics for one or more painful conditions. The "adjuvant" designation reflects their early use as opioid co-analgesics for cancer pain. During the past 3 decades, their role in pain management has changed with the advent of many new entities, emerging data from numerous analgesic trials, and growing clinical experience. Many of these drugs are now used as primary analgesics for specific types of chronic pain. With proper patient selection and cautious administration, they can potentially contribute meaningfully to the management of chronic pain in older adults. A practical approach categorizes the many adjuvant analgesics by broad indications: multipurpose drugs and drugs that target neuropathic pain, musculoskeletal pain, and cancer pain, respectively. This article reviews the status of the evidence supporting the analgesic potential of the adjuvant analgesics and discusses best practices in terms of drug selection and dosing. J Am Geriatr Soc 68:691-698, 2020.

Medication use and cognitive impairment among residents of aged care facilities

BACKGROUND

Potentially inappropriate polypharmacy is common in residential aged care facilities (RACF). This is of particular concern among people with cognitive impairment who, compared with cognitively intact residents, are potentially more sensitive to the adverse effects of medications.

AIM

To compare the patterns of medication prescribing of RACF residents based on cognitive status.

METHODS

De-identified data collected during telehealth-mediated geriatric consultations with 720 permanent RACF residents were analysed. Residents were categorised into cognitively intact, mild to moderate impairment and severe impairment groups using the interRAI Cognitive Performance Scale. The number of all regular and when-required medications used in the past 3 days, the level of exposure to anti-cholinergic/sedative medications and potentially inappropriate medications and the use of preventive and symptom control medications were compared across the groups.

RESULTS

The median number of medications was 10 (interquartile range (IQR) 8-14). Cognitively intact residents were receiving significantly more medications (median (IQR) 13 (10-16)) than those with mild to moderate (10 (7-13)) or severe (9 (7-12)) cognitive impairment (P < 0.001). Overall, 82% of residents received at least one anti-cholinergic/sedative medication and 26.9% were exposed to one or more potentially inappropriate medications, although the proportions of those receiving such medications were not significantly different across the groups. Of 7658 medications residents were taking daily, 21.3% and 11.7% were classified as symptom control and preventive medications respectively with no significant difference among the groups in their use.

CONCLUSION

Our findings highlight the need for optimising prescribing in RACF residents, with particular attention to medications with anti-cholinergic effects.

Predictors of unplanned hospitalisation in the older population: The role of polypharmacy and other medication and chronic disease-related factors

OBJECTIVE

To identify demographic and medication-related predictors of unplanned hospitalisation and combine them into a hospitalisation risk score.

METHODS

Patients aged ≥65 years from an outpatient multimorbidity clinic were included. Hospitalisation predictors within a year of clinic discharge were identified using logistic regression. A risk score was developed. The area under the curve (AUC) was used to assess its predictive ability, compared to that of the medicines count (definition of polypharmacy).

RESULTS

A total of 598 patients were included (median age of 80.0 years). 58.0% (n = 347) were hospitalised within a year of clinic discharge. The AUC for the risk score incorporating age, medicines count, heart failure (HF), atherosclerotic disease and systemic steroids was 0.67 [95% CI 0.62-0.71], compared to 0.62 [95% CI 0.58-0.67] for the medicines count.

CONCLUSION

A hospitalisation risk score incorporating demographics, medicines, namely steroids, and diseases such as HF had increased predictive ability compared to the medicines count, providing guidance for developing future polypharmacy tools.

An Advanced Two-Step DNN-Based Framework for Arrhythmia Detection

Heart arrhythmia is a severe heart problem. Automated heartbeat classification provides a cost-effective screening for heart arrhythmia and allows at-risk patients to receive timely treatments, which is a highly demanded but challenging task. Recent works have brought visible improvements to this area, but to identify the problematic supraventricular ectopic (S-type) heartbeats is still a bottleneck in most existing studies. This paper presents a two-step DNN-based framework to identify arrhythmia-related heartbeats. In the first step, a deep dual-channel convolutional neural network (DDCNN) is proposed to classify all heartbeat classes, except for the normal and S-type heartbeats. In the second stage, a central-towards LSTM supportive model (CLSM) is specially designed to distinguish S-type heartbeats from the normal ones. By processing heart rhythms in central-towards directions, CLSM learns and abstracts hidden temporal information between a heartbeat and its neighbors to reveal the deep differences between the two heartbeat types. As an improvement, we also propose a rule-based data augmentation method to solve the training data imbalance problem. The proposed framework is evaluated over three real-world ECG databases. The results show that our method outperforms the baselines in most evaluation metrics.

Association between potentially inappropriate medications at discharge and unplanned readmissions among hospitalised elderly patients at a single centre in Japan: a prospective observational study

OBJECTIVE

To determine the prevalence of potentially inappropriate medication (PIM) use at admission and discharge among hospitalised elderly patients and evaluate the association between PIMs at discharge and unplanned readmission in Japan.

DESIGN

A prospective observational study conducted by using electronic medical records.

PARTICIPANTS

All consecutive patients aged 65 years or older who were admitted to the internal medicine ward were included. Patients who were electively admitted for diagnostic procedures were excluded.

MAIN OUTCOME MEASURES

The primary outcome was 30-day unplanned readmissions. The secondary outcome was the prevalence of any PIM use at admission and discharge. PIMs were defined based on the Beers Criteria. The association between any PIM use at discharge and the primary outcome was evaluated by using logistic regression.

RESULTS

Seven hundred thirty-nine eligible patients were included in this study. The median patient age was 82 years (IQR 74-88); 389 (52.6%) were women, and the median Charlson Comorbidity Index was 2 (IQR 0-3). The proportions of patients taking any PIMs at admission and discharge were 47.2% and 32.2%, respectively. Of all the patients, 39 (5.3%) were readmitted within 30 days after discharge for the index hospitalisation. The use of PIMs at discharge was not associated with an increased risk of 30-day readmission (OR 0.93; 95% CI 0.46 to 1.87). This result did not change after adjusting for patient age, sex, number of medications, duration of hospital stay and comorbidities (OR 0.78; 95% CI 0.36 to 1.66).

CONCLUSION

The prevalence of any PIM use at discharge was high among hospitalised elderly patients in a Japanese hospital. Although the use of PIMs at discharge was not associated with an increased risk of unplanned readmission, given a lack of power of this study due to a low event rate, further studies investigating this association are needed.

TRIAL REGISTRATION NUMBER

UMIN000027189.

Cognitive modelling of Chinese herbal medicine's effect on breast cancer

Purpose

Traditional Chinese medicine (TCM) has recently attracted increasing interests in cancer treatment. It was found that TCM-based treatment, combined with other therapies, can help improve patients' life quality. However, the existing research in TCM lacks a systematic modelling for the causal relationship of the factors related to the diagnosis and decision making.

Methods

In this paper, we proposed the use of fuzzy cognitive map (FCM) to represent the cognition of TCMs usage in cancer treatment.

Results

Through a case analysis, we analyse and summarise the effects of Chinese herbal medicine in breast cancer management.

Conclusion

FCMs can visually represent the cognitive knowledge, particularly the causal relationship among key factors of TCM effects and the related breast cancer status.

Neural attention with character embeddings for hay fever detection from twitter

The paper aims to leverage the highly unstructured user-generated content in the context of pollen allergy surveillance using neural networks with character embeddings and the attention mechanism. Currently, there is no accurate representation of hay fever prevalence, particularly in real-time scenarios. Social media serves as an alternative to extract knowledge about the condition, which is valuable for allergy sufferers, general practitioners, and policy makers. Despite tremendous potential offered, conventional natural language processing methods prove limited when exposed to the challenging nature of user-generated content. As a result, the detection of actual hay fever instances among the number of false positives, as well as the correct identification of non-technical expressions as pollen allergy symptoms poses a major problem. We propose a deep architecture enhanced with character embeddings and neural attention to improve the performance of hay fever-related content classification from Twitter data. Improvement in prediction is achieved due to the character-level semantics introduced, which effectively addresses the out-of-vocabulary problem in our dataset where the rate is approximately 9%. Overall, the study is a step forward towards improved real-time pollen allergy surveillance from social media with state-of-art technology.

Proton Pump Inhibitors and Infection-Related Hospitalizations Among Residents of Long-Term Care Facilities: A Case-Control Study

OBJECTIVE

Our objective was to investigate associations between proton pump inhibitor (PPIs) use and infection-related hospitalizations among residents of long-term care facilities (LTCFs).

METHODS

This was a case-control study of residents aged ≥ 65 years admitted to hospital between July 2013 and June 2015. Residents admitted for infections (cases) and falls or fall-related injuries (controls) were matched for age (± 2 years), sex, and index date of admission (± 6 months). Conditional logistic regression was used to estimate crude and adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between PPI use and infection-related hospitalizations. Analyses were adjusted for age, sex, polypharmacy, diabetes, heart failure, chronic obstructive pulmonary disease, myocardial infarction, cerebrovascular accident, and concomitant use of cancer and immunosuppressant medications. Subgroup analyses were performed for high- and low/moderate-intensity PPIs and for respiratory and non-respiratory infections. Logistic regression was used to compare the odds of infection-related hospitalizations among users of high- and low/moderate-intensity PPIs.

RESULTS

Overall, 181 cases were matched to 354 controls. Preadmission PPI use was associated with infection-related hospitalizations (aOR 1.66; 95% CI 1.11-2.48). In subgroup analyses, the association was apparent only for respiratory infections (aOR 2.26; 95% CI 1.37-3.73) and high-intensity PPIs (aOR 1.93; 95% CI 1.23-3.04). However, the risk of infection-related hospitalization was not significantly higher among users of high- versus low/moderate-intensity PPIs (aOR 1.25; 95% CI 0.74-2.13).

CONCLUSION

Residents who use PPIs may be at increased risk of infection-related hospitalizations, particularly respiratory infections. Study findings provide further support for initiatives to minimize unnecessary PPI use in the LTCF setting.

Unobtrusive Mattress-Based Identification of Hypertension by Integrating Classification and Association Rule Mining

Hypertension is one of the most common cardiovascular diseases, which will cause severe complications if not treated in a timely way. Early and accurate identification of hypertension is essential to prevent the condition from deteriorating further. As a kind of complex physiological state, hypertension is hard to characterize accurately. However, most existing hypertension identification methods usually extract features only from limited aspects such as the time-frequency domain or non-linear domain. It is difficult for them to characterize hypertension patterns comprehensively, which results in limited identification performance. Furthermore, existing methods can only determine whether the subjects suffer from hypertension, but they cannot give additional useful information about the patients’ condition. For example, their classification results cannot explain why the subjects are hypertensive, which is not conducive to further analyzing the patient’s condition. To this end, this paper proposes a novel hypertension identification method by integrating classification and association rule mining. Its core idea is to exploit the association relationship among multi-dimension features to distinguish hypertensive patients from normotensive subjects. In particular, the proposed method can not only identify hypertension accurately, but also generate a set of class association rules (CARs). The CARs are proved to be able to reflect the subject’s physiological status. Experimental results based on a real dataset indicate that the proposed method outperforms two state-of-the-art methods and three common classifiers, and achieves 84.4%, 82.5% and 85.3% in terms of accuracy, precision and recall, respectively.

Potentially inappropriate medications according to STOPP-J criteria and risks of hospitalization and mortality in elderly patients receiving home-based medical services

Background

Although potentially inappropriate medications (PIMs) have been linked to poor health outcomes, country-specific PIM criteria have not been compared. Thus, we compared the identification of PIMs between the Screening Tool for Older Person’s Appropriate Prescriptions for Japanese (STOPP-J) and the 2015 American Geriatrics Society Beers Criteria in elderly patients receiving home-based medical services.

Methods

A 5-year prospective cohort study was conducted with 196 patients receiving home-based medical services. Data were collected using questionnaires and chart reviews and included detailed information on prescription medication. STOPP-J and the Beers Criteria were used to categorize PIM and non-PIM recipients. All-cause mortality and first hospitalization were compared using a multivariate Cox regression model.

Results

PIMs were detected in 132 patients (67.3%) by STOPP-J and in 141 patients (71.9%) by the Beers Criteria, and the mean numbers of PIMs were 1.3 ± 1.3 and 1.2 ± 1.1, respectively. The three most frequently prescribed STOPP-J PIMs were hypnotics (26.8%), diuretics (25.6%), and NSAIDs (12.6%), compared with proton pump inhibitors (PPIs) (29.8%), hypnotics (26%), and NSAIDs (8.1%) according to the Beers Criteria. STOPP-J PIMs were associated with all-cause mortality (HR 3.01, 95% CI 1.37–6.64) and hospitalization (HR 1.91, 95% CI 1.17–3.09); neither was associated with Beers Criteria PIMs. Using a modified Beers Criteria (excluding PPIs), PIMs were correlated with first hospitalization (HR 1.91, 95% CI 1.17–3.09).

Conclusions

PIMs categorized by STOPP-J are associated with hospitalization and mortality in Japanese patients receiving home-based medical services. PPIs, commonly used for acid-related diseases, do not seem to have deleterious effects on health outcomes. Country-oriented, medication-specific criteria would be of considerable clinical utility.