The patterns and burden of multimorbidity in geriatric patients with prolonged use of addictive medications

Validation of the Internal Coherence Scale (ICS) in Healthy Geriatric Individuals and Patients Suffering from Diabetes Mellitus Type 2 and Cancer

BACKGROUND

With increased life expectancy, the coexistence of functional impairment and multimorbidity can negatively impact life quality and coherence in geriatric individuals. The self-report 10-item Internal Coherence (ICS) measures how individuals cope with and make sense of disease-specific life challenges. The aim of this study was to validate the ICS in a sample of geriatric individuals.

METHODS AND PROCEDURE

In a cross-sectional study, geriatric individuals with and without chronic diseases were recruited. A factor analysis with principal component extraction (PCA) and a structural equation model (SEM) was conducted to assess the ICS factor structure in a geriatric sample. To measure convergent validity, the following scales were used: Short Health Survey (SF-12), Karnofsky Performance Index (KPI), Trait autonomic regulation (Trait aR), Sense of Coherence Scale (SOC), and Geriatric Depression Scale (GDS).

RESULTS

A sample of n = 104 (70-96 years of age) patients with Diabetes Mellitus Type 2 (n = 22), cancer diseases (n = 31) and healthy controls (n = 51) completed the ICS. PCA and SEM yielded the original two-factor solution: 1. Inner resilience and coherence and 2. Thermo coherence. Overall internal consistency for this cohort was satisfying (Cronbach's α with rα = 0.72), and test-retest reliability was moderate (rrt = 0.53). ICS scores were significantly correlated to all convergent criteria ranging between r = 0.22 * and 0.49 ** (p < 0.05 *; p < 0.01 **).

CONCLUSION

Study results suggest that the ICS appears to be a reliable and valid tool to measure internal coherence in a geriatric cohort (70-96 years). However, moderate test-retest reliability prompts the consideration of potential age-effects that may bias the reliability for this specific cohort.

Measuring pain intensity in older adults. Can the visual analogue scale and the numeric rating scale be used interchangeably?

OBJECTIVES

Visual analogue scale (VAS) and numeric rating scale (NRS) are two commonly used instruments for measuring pain intensity. Both instruments are validated for use in both clinical and research settings, and share a range of similar aspects. Some studies have shown that the two instruments may be used interchangeably, but the results are conflicting. In this study we assessed whether the VAS and the NRS instruments may be used interchangeably when measuring pain intensity in older adults.

METHODS

Data were collected in a cross-sectional study, as part of the follow-up in a larger longitudinal study conducted at the Akershus University Hospital, Norway 2021 to 2022 and included 39 older adults aged ≥65. Participants were regarded as a normal older adult population as they were not recruited on basis of a specific condition or reports of pain. The participants were asked to rate their pain intensity on an average day using VAS and NRS. Bland-Altman analysis was performed to assess agreement between the two instruments.

RESULTS

Thirty-seven participants with mean (SD) age of 77 (5.9) were included in the analysis. Mean (SD) pain assessed by VAS and NRS was 2.8 (1.8) and NRS 4.7 (2.2), respectively. A mean difference (SD) of 2.0 (1.9) between the scores of the two instruments was statistically significantly different from zero (p < 0.001) confirming bias. The 95% limits of agreement were estimated to be -1.7 to 5.7. A post-hoc analysis, removing an outlier, resulted in similar conclusions.

CONCLUSION

There was poor agreement between the VAS and NRS scale for measuring pain intensity in older adults. This suggests that the two instruments should not be used interchangeably when assessing pain intensity in this population.

ETHICAL APPROVAL

Regional Committees for Medical and Health Research Ethics [2016/2289].

TRIAL REGISTRATION

NCT03162081, 22 May 2017.

Mortality and health-related quality of life in older adults with long-term use of opioids, z-hypnotics or benzodiazepines: a prospective observational study at 5 years follow-up

OBJECTIVES

Disease and medication use in older age is a consequence of age-related declining health. Multimorbidity followed by polypharmacy is common. Central nervous system depressing (CNSD) drugs such as opioids, benzodiazepines and z-hypnotics are not recommended for long-term use in older adults but are in use by many. We aimed to assess mortality and change in health-related quality of life (HRQoL) in older adults with long-term use of CNSDs.

METHOD

A prospective observational study was conducted at Akershus University Hospital, Norway, 2017-2019, with follow-up in 2021-2022, including 246 participants aged 65-90. At 5-year follow-up, 78 (32%) participants had passed away. Mortality data were collected from patient electronic health records. Of the surviving 168 (68%), we collected further follow-up data from 38 (16%) participants. Follow-up included demographic and clinical data. The EuroQuol Group EQ-5D-5L questionnaire was used to measure HRQoL. Analysis include Cox regression model for survival data and linear mixed model for change in HRQoL over time.

RESULTS

At follow-up, 78 (31.7%) were deceased. Mean survival time was 3.3 years. Total time for survival data was 4.7 years. Mortality was higher among participants with long-term use of CNSD (HR 1.9 95% CI (1.2 to 3.2), p=0.01). The multivariable analysis found being older (HR 1.1 95% CI (1.0 to 1.1), p=0.020) and male sex (HR 2.1 95% CI (1.2 to 3.5), p=0.008) to be associated with increased risk of mortality. According to the linear mixed model (n=38), there was no significant difference between surviving users and non-users in change in HRQoL EQ-5D-5L index from baseline to follow-up.

CONCLUSION

Mortality was higher for long-term users of CNSDs at 5-year follow-up. Being older and male sex were associated with mortality. Among survivors, there was no significant difference between the groups in change of HRQoL over time.

TRIAL REGISTRATION NUMBER

NCT03162081; 22 May 2017.

Brief Intervention as a Method to Reduce Z-Hypnotic Use by Older Adults: Feasibility Case Series

BACKGROUND

Z-hypnotics or z-drugs are commonly prescribed for insomnia and sleep difficulties in older adults. These drugs are associated with adverse events and dependence and are not recommended for long-term use. Despite evidence of older adults being more sensitive to a wide array of adverse events and clinical guidelines advocating limiting use, inappropriate use in this population is still prevalent. Previous intervention studies have focused mainly on prescriber information. Simple, individually focused intervention designs are less studied. Brief intervention (BI) is a simple, easily transferable method mainly used to treat patients at risk of alcohol overuse.

OBJECTIVE

Our objective was to design and test the feasibility and acceptability of a BI intervention adapted to address individual, inappropriate use of z-hypnotics among older adults. This preparatory study aimed to optimize the intervention in advance of a quantitative randomized controlled trial investigating the treatment effect in a larger population.

METHODS

This feasibility case series was conducted at Akershus University Hospital, Norway, in autumn 2021. We included 5 adults aged ≥65 years with long-term (≥4 weeks) use of z-hypnotics and 2 intervening physicians. Additionally, 2 study investigators contributed with process evaluation notes. The BI consists of information on the risk of inappropriate use and individualized advice on how to reduce use. The focus of the intervention is behavioral and aims, in cooperation with the patient and based on shared decision-making, to change patient behavior regarding sleep medication rather than physician-based detoxification and termination of z-hypnotic prescriptions. Qualitative and descriptive quantitative data were collected from intervening physicians, study investigators, and participants at baseline, immediately after the intervention, and at the 6-week follow-up.

RESULTS

Data were obtained from 2 physicians, 2 study investigators, and 5 participants (4 women) with a median age of 84 years. The average time spent on the BI consultation was 15 minutes. All 5 participants completed the intervention without problems. The participants and 2 intervening physicians reported the intervention as acceptable and were satisfied with the delivery of the intervention. After the intervention, 2 participants stopped their use of z-hypnotics completely and participated in the follow-up interview. Study investigators identified logistical challenges regarding location and time requirements. Identified aspects that may improve the intervention and reduce dropouts included revising the intervention content, focusing on rebound insomnia, adding an information leaflet, and supporting the patient in the period between the intervention and follow-up. The notion that the intervention should best be located and conducted by the patient's own general practitioner was supported by the participants.

CONCLUSIONS

We identified important aspects to improve the designed intervention and found that the BI is feasible and acceptable for incorporation into a larger randomized trial investigating the treatment effect of BI for reducing z-hypnotic use by older adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03162081; http://tinyurl.com/rmzx6brn.

The (Mis)use of Psychotropic Drugs and Addiction to Anxiolytics among Older Adults Living at Home or in Retirement Homes: Implications for Quality of Life

Nowadays, the growing number of people aged 65+ has become a global phenomenon. At that age, the most common medical problems are multimorbidity and inappropriate polypharmacy, which have a negative impact on the quality of life in older adults. The aim of this cross-sectional study was to examine comorbidity, the use of psychopharmaceuticals, and symptoms of addiction to anxiolytics among older adults living at home or in retirement homes, and to examine the differences in quality of life in relation to the use and misuse of psychotropic drugs. The research included 383 people aged 65+ living in the Republic of Croatia (EU). A standardized questionnaire CAGE was used to collect data about the use of psychotropic drugs. Quality of life was examined using the WHOQOL-BREF scale. The average age of respondents was 83 years. There is a significantly higher prevalence of anxiety disorders (p = 0.001) in respondents who live at home. Psychopharmaceuticals were used by 218 (56.9%) respondents, equally in both groups of respondents. A total of 77 (20.1%) respondents had been using anxiolytics for more than five years, while 26 (6.8%) of them had significant clinical symptoms of addiction to anxiolytics. All domains and the overall quality of life scale were significantly lower (p < 0.001) in respondents who have clinical symptoms of anxiolytic addiction. The results indicate that the use of psychotropic drugs by respondents is inappropriate. Respondents who inappropriately and excessively use psychotropic drugs have a significantly worse quality of life.

The association between pain and central nervous system depressing medication among hospitalised Norwegian older adults

OBJECTIVES

Central nervous system depressant medications (CNSD) including benzodiazepines, z-hypnotics and opioids are regularly prescribed for the older patient. These medications are linked to dependence and associated with severe side effects in some older patients. Consensus recommendations for this group suggest limiting their use. We have recently described a high proportion of long-term CNSD use and dependence among older in-hospital patients. In this study, we aim to investigate factors associated with pain intensity and presentation of pain among older adults with long-term use of CNSDs compared to non-users.

METHODS

Two hundred and forty six elderly hospitalised patients were recruited consecutively in a cross-sectional study. Data was collected from patients and electronic health records (EHR). Independent variables were sex, age, education, emotional symptoms (hospital anxiety and depression scale [HADS]), cognitive function (Mini-mental State Examination test [MMSE]), comorbidity (cumulative illness rating score - geriatrics [CIRS-G]), loneliness (the six-item De Jong Gierveld Loneliness Scale) and prolonged (≥4 weeks) use of any CNSDs or prolonged use of opioids (≥4 weeks). All variables, including pain intensity, were collected at one time point consistent with the cross-sectional study design. Statistical analyses included descriptive statistics and linear regression models using the above mentioned variables and pain intensity (visual analogue scale for pain intensity [VAS] pain 0-100) as outcome. Additional information regarding pain presentation was extracted from the patients' EHR.

RESULTS

Mean pain intensity VAS (SD) was 35.2 (30.4) and 18.1 (24.2) respectively, for patients with vs. without prolonged use of CNSDs. In the multivariable linear regression analysis, prolonged use of CNSDs and opioids were positively associated with pain intensity (VAS) (regression coefficient (95% CI) 20.7 (11.0; 30.3), p<0.001, and 19.8 (5.7; 33.8), p=0.006, respectively), while sex, age, education, MMSE, HADS, CIRS-G and loneliness scores were not. Pain related to back (23.2%) and lower extremities (23.2%) were most common pain sites, and those with one or more pain sites reported overall higher pain intensity compared to those with no reported pain sites (p<0.006).

CONCLUSIONS

Prolonged use of CNSD medications as well as prolonged use of opioids are both positively associated with pain intensity. The results may have implications for treatment and long-term pain management for older patients.