Association between comprehensive geriatric assessment and polypharmacy at discharge in patients with ischaemic stroke: A nationwide, retrospective, cohort study

Effectiveness of comprehensive geriatric assessment in frail older inpatients

BACKGROUND

Evidence regarding the effects of comprehensive geriatric assessment (CGA) on frail older inpatients is inconclusive. Moreover, various prior studies lacked proper patient selection using frailty assessment tools. Our review aimed to assess whether objectively identifying frail patients in clinical settings using a frailty tool and intervening with CGA provides clinical benefits in frail older inpatients.

METHODS

A systematic review and meta-analysis were conducted by searching PubMed, Embase, and Web of Science (January 1998-October 2022). Keywords included frailty, hospitalization, and CGA. Eligible studies were randomized controlled trials involving patients aged ≥65 years, with frailty defined by specific tools. The primary outcome was mortality; secondary outcomes included activities of daily living, quality of life, pain, patient satisfaction, polypharmacy, antidepressant use, post-discharge disposition, rehospitalization, and cost-effectiveness.

RESULTS

Of 2587 articles, 18 met inclusion criteria (2724 participants). Meta-analysis of five studies showed no significant differences in overall mortality for frail inpatients receiving CGA. However, CGA reduced mortality during follow-ups of ≤6 months. CGA also improved health-related quality of life, patient satisfaction, and activities of daily living, while reducing polypharmacy and modifying antidepressant use.

CONCLUSIONS

CGA did not significantly reduce overall mortality in frail older inpatients compared to usual care but lowered mortality rates at the 6-month follow-up. CGA also improved quality of life, daily functioning, and medication management, underscoring its value for managing frail older inpatients.

Do Orally Disintegrating Tablets Facilitate Medical Adherence and Clinical Outcomes in Patients with Post-stroke Dysphagia?

Orally disintegrating tablets (ODTs) dissolve rapidly in contact with saliva and have been reported to facilitate oral administration of medications in swallowing difficulties. However, their clinical benefits remain unclear because no previous studies have examined whether ODTs facilitate medication adherence and clinical outcomes in patients with post-stroke dysphagia. This study evaluated the association between ODT prescriptions and clinical benefits using high-dimensional propensity score (hd-PS) matching to adjust for confounding factors. Using a large Japanese commercial medical and dental claims database, we identified patients aged ≥ 65 years with post-stroke dysphagia between April 2014 and March 2021. To compare 1-year outcomes of medication adherence, cardiovascular events, and aspiration pneumonia between patients taking ODTs and non-ODTs, we performed hd-PS matching. We identified 11,813 patients without ODTs and 3178 patients with ODTs. After hd-PS matching, 2246 pairs were generated. Medication adherence for 1 year, based on the proportion of days covered, was not significantly different between the non-ODT and ODT groups before (0.887 vs. 0.900, P = 0.999) and after hd-PS matching (0.889 vs. 0.902, P = 0.977). The proportion of cardiovascular events (0.898 vs. 0.893, P = 0.591) and aspiration pneumonia (0.380 vs. 0.372, P = 0.558) were also not significantly different between the groups. This study found no significant differences in medication adherence, cardiovascular diseases, or aspiration pneumonia between the non-ODT and ODT groups in patients with post-stroke dysphagia. Both groups achieved a proportion of days covered exceeding 80%. Clinicians may consider prescribing ODTs or non-ODTs based on patient preferences rather than solely on post-stroke conditions.

Efficacy and safety of brain-computer interface for stroke rehabilitation: an overview of systematic review

Background

Stroke is a major global health challenge that significantly influences public health. In stroke rehabilitation, brain-computer interfaces (BCI) offer distinct advantages over traditional training programs, including improved motor recovery and greater neuroplasticity. Here, we provide a first re-evaluation of systematic reviews and meta-analyses to further explore the safety and clinical efficacy of BCI in stroke rehabilitation.

Methods

A standardized search was conducted in major databases up to October 2024. We assessed the quality of the literature based on the following aspects: AMSTAR-2, PRISMA, publication year, study design, homogeneity, and publication bias. The data were subsequently visualized as radar plots, enabling a comprehensive and rigorous evaluation of the literature.

Results

We initially identified 908 articles and, after removing duplicates, we screened titles and abstracts of 407 articles. A total of 18 studies satisfied inclusion criteria were included. The re-evaluation showed that the quality of systematic reviews and meta-analyses concerning stroke BCI training is moderate, which can provide relatively good evidence.

Conclusion

It has been proven that BCI-combined treatment can improve upper limb motor function and the quality of daily life for stroke patients, especially those in the subacute phase, demonstrating good safety. However, its effects on improving speech function, lower limb motor function, and long-term outcomes require further evidence. Multicenter, long-term follow-up studies are needed to increase the reliability of the results.

Clinical Trial Registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024562114, CRD42023407720.

Effect of a Financial Incentive Scheme for Medication Review on Polypharmacy in Elderly Inpatients With Dementia: A Retrospective Before-and-After Study

OBJECTIVES

Polypharmacy is an important healthcare issue, especially in elderly patients with dementia. As an incentive to reduce polypharmacy, a health insurance reimbursement scheme was introduced in 2016 for medication review and the reduction of medications for inpatients in Japan. However, the effects of these incentive schemes were not evaluated.

METHODS

We identified 1,465,881 inpatients aged ≥65 years with dementia. An interrupted time-series analysis was conducted by fitting a Prais-Winsten linear regression model. The outcome measure was the number of classes of medications prescribed during discharge.

RESULTS

No significant changes were observed in the average number of medication classes at discharge immediately after the introduction of the scheme (coefficient: -0.022, 95% confidence interval [CI]: -0.17 to 0.13). The slope change, representing the effect of the intervention over time, was also not significant (coefficient: -0.00053, 95% confidence interval: -0.0012 to 0.00018).

CONCLUSIONS

The incentive scheme was not associated with a reduction in the number of medication classes at discharge among older inpatients with dementia.

Incidence of new fractures in older patients with osteoporosis receiving biosimilar teriparatide or reference products: A retrospective cohort study

AIMS

Biosimilar products have clinical characteristics similar to those of brand-name products and can reduce medical costs. However, the use of biosimilar products for osteoporosis treatments remains limited due to concerns regarding its safety and efficacy. We aimed to clarify the effectiveness and safety of the biosimilar teriparatide compared with those of the reference product using the incidence of new fractures and osteosarcoma as outcomes in osteoporosis patients.

METHODS

This study used the DeSC database, which contains medical claims data for various insurers in Japan. We included patients with osteoporosis aged ≥65 years who newly received either biosimilar teriparatide or the reference products between April 2019 and November 2022. Competing risk analyses were performed with adjustments for patient characteristics. The primary and secondary outcomes were the occurrence of new fractures and osteosarcoma, respectively.

RESULTS

Among 45 861 included patients, 3613 and 42 248 were in the biosimilar and reference product groups, respectively. The median follow-up duration was 439 days. New fractures occurred in 6.7% of patients. Cumulative incidence function curves showed similar risks of new fractures over time in both groups. The cause-specific hazard ratio for new fractures was 0.95 (95% confidence interval: 0.82-1.11) for the biosimilar group compared with that of the reference product group. The incidence of osteosarcoma did not differ significantly between the groups (P = .559).

CONCLUSIONS

The biosimilar teriparatide showed effectiveness and safety comparable with those of the reference products in treating osteoporosis patients. Our results suggest that clinicians need not hesitate to prescribe biosimilar teriparatide for osteoporosis patients.

Comprehensive Gerontological Assessment: An Update on the Concept and Its Evaluation Tools in Latin America and the Caribbean-A Literature Review

In recent decades, Latin America and the Caribbean region have experienced accelerated aging. However, despite the significant progress of gerontology in the region, the number of geriatricians and professionals trained in the field is low; a notable gap in the training related to the assessment of older adults can also be observed. Therefore, in this literature review, we update the concept of Comprehensive Gerontological Assessment (CGA) for its application in the region. We compile the characteristics, validity, and reliability of CGA tools, and their usage in government documents across countries in the region. We also analyze the adaptations made to CGA during the COVID-19 pandemic, and discuss challenges related to CGA administration, academic training, research, innovation, and management. This study is particularly relevant as it proposes lines of action for decision-makers, academics, researchers, university students, and the general community, which will allow for more tailored interventions aimed at meeting the needs of older adults, their families, and caregivers. Such actions will positively impact functionality, autonomy, and quality of life, while promoting healthy, active, and successful aging in the region.

Implementation status of comprehensive geriatric assessment among older inpatients: A nationwide retrospective study

AIM

The importance of comprehensive geriatric assessment (CGA) is increasing in aging societies worldwide. However, there are few comprehensive studies on CGA, resulting in a limited understanding of its implementation rate, temporal changes and factors associated with its implementation. We aimed to investigate the implementation status of CGA and its regional variance in Japan.

METHODS

Using the Diagnosis Procedure Combination database, we investigated CGA trends, and identified the patient, hospital and regional factors associated with its implementation. We identified patients aged ≥65 years who were admitted for the first time between 2016 and 2020 with a diagnosis of stroke, heart failure, pneumonia, bone fracture or colorectal cancer. We examined the CGA implementation rate according to patient and hospital characteristics. We also investigated temporal changes and tendencies to carry out CGA in different prefectures.

RESULTS

A total of 1 974 817 patients were analyzed, of whom 570 696 (28.9%) underwent CGA. The implementation trend increased steadily from 25.3% in fiscal year 2016 to 33.4% in fiscal year 2019. The implementation rate also increased with patient age (30.3% in patients aged ≥95 years). Regional variations in its implementation status were observed, with a higher tendency to be implemented in areas near major metropolitan regions. A trend toward carrying out CGA for colorectal cancer, but not for other diseases, has been observed in eastern Japan.

CONCLUSION

Although CGA is increasingly carried out, considerable regional differences remain in its implementation status. Initiatives to reduce variations are necessary. Geriatr Gerontol Int 2024; 24: 904-911.

Association between self-reported difficulty in chewing or swallowing and frailty in older adults: A retrospective cohort study

Oral frailty can contribute to physical and mental health disorders. Previous research has shown an association between frailty and self-reported difficulty in chewing or swallowing. However, their combined assessment has obscured their specific impact on frailty-related outcomes. To investigate the independent associations between difficulty in chewing or swallowing and 1-year frailty outcomes, while also examining their interactions. This retrospective cohort study utilized the DeSC database to identify older adults aged ≥ 75 years who underwent health checkups between April 2014 and November 2022. Multivariate Cox regression analyses were conducted to assess the association between self-reported difficulty in chewing or swallowing and outcomes, including hospitalization due to aspiration pneumonia, all-cause hospitalization, and all-cause mortality within 1 year. Interactions between chewing and swallowing difficulties were also evaluated. Among 359,111 older adults, 39.0% reported oral function difficulties. Swallowing difficulty alone lacked significant outcome association. However, chewing difficulty alone was significantly associated with higher risks of hospitalization due to aspiration pneumonia (hazard ratio (HR), 1.35; 95% confidence interval (CI), 1.15-1.58; P < 0.001), all-cause hospitalization (HR, 1.08; 95% CI, 1.05-1.11; P < 0.001), and all-cause mortality (HR, 1.28; 95% CI, 1.14-1.44; P < 0.001) compared with no self-reported difficulty. A significant positive interaction between self-reported difficulty in chewing and swallowing was observed for all-cause mortality (P = 0.009). Self-reported difficulty in chewing was significantly associated with higher risks of hospitalization due to aspiration pneumonia, all-cause hospitalization, and all-cause mortality among older adults. Chewing and swallowing difficulties showed a synergistic effect, significantly increasing all-cause mortality risk.

Association between subjective physical function and occurrence of new fractures in older adults: A retrospective cohort study

BACKGROUND

The Late-Stage Elderly Questionnaire has been incorporated into health assessments for older adults in Japan, encompassing three self-administered questions on subjective physical function: subjective gait speed decline, recent fall history, and exercise habits. Nevertheless, its efficacy in predicting new fracture occurrences remains uncertain.

METHODS

This retrospective cohort study utilized Japan's DeSC database, a large commercially available claims database. Participants were older adults aged ≥75 years and provided complete responses to the Late-Stage Elderly Questionnaire at health check-ups. We performed two Cox regression analyses for new fractures based on the responses to the three questions (Model 1) and on age, sex, and responses to the three questions (Model 2). The predictive abilities of the 1-year occurrence of new fractures were compared between the two models.

RESULTS

Of 11 683 eligible older adults, 927 (7.93%) experienced new fractures. Model 1 revealed significant associations between new fractures and subjective gait speed decline (hazard ratio [HR], 1.63; 95% confidence interval [CI], 1.40-1.89), recent fall history (HR, 2.03; 95% CI, 1.77-2.33), and absence of exercise habits (HR, 1.29; 95% CI, 1.13-1.47). Model 2 demonstrated superior predictive ability (area under the curve, 0.677; 95% CI, 0.659-0.695) compared with Model 1 (area under the curve, 0.633; 95% CI, 0.614-0.652), with a net reclassification improvement of 0.383 (95% CI, 0.317-0.449).

CONCLUSION

Three subjective physical well-being factors were significantly associated with new fracture development in older adults. These results suggest that the three-question assessment may be a valuable screening tool for identifying new fractures. Geriatr Gerontol Int 2024; 24: 337-343.

Association between Cognitive Impairment Severity and Polypharmacy in Older Patients with Atrial Fibrillation: A Retrospective Study Using Inpatient Data from a Specialised Geriatric Hospital

This study aimed to investigate the association between cognitive impairment and polypharmacy in patients with atrial fibrillation prone to cognitive decline, and to elucidate if the Dementia Assessment Sheet for Community-based Integrated Care System 21-Items (DASC-21) severity classification indicates drug adjustment. This retrospective cohort study used the DASC-21 and Diagnosis Procedure Combination data at a specialised geriatric hospital with patients hospitalised between April 2019 and March 2022. The association between cognitive severity evaluated using the DASC-21 and polypharmacy was investigated using a multivariate logistic regression model. Data of 1191 inpatients (44.3% aged ≥85 years, 49.0% male) were analysed. Compared with severe cognitive impairment, mild (odds ratio [OR]: 3.33, 95% confidence interval [CI]: 1.29-8.57) and moderate (OR: 2.46, 95% CI: 1.06-5.72) impairments were associated with concurrent use of ≥6 medications. Antithrombotics were related to polypharmacy. The ORs did not change with 6, 8, or 10 medications (2.11 [95% CI: 1.51-2.95, p < 0.001], 2.42 [95% CI: 1.79-3.27, p < 0.001], and 2.01 [95% CI: 1.46-2.77, p < 0.001], respectively). DASC-21 severity was associated with polypharmacy in patients with atrial fibrillation, with a trend toward decreased polypharmacy from moderate to severe. The DASC-21 may serve as an indicator for drug adjustment in clinical practice.

Association between the type of hypnotic drug and in-hospital fractures in older patients with neurocognitive disorders: A case-control study using a nationwide database

AIM

Hypnotics might increase the risk of falls and fractures in older patients with neurocognitive disorders. Orexin receptor antagonists have recently been approved, but the relationship between the new drugs and fractures remains unclarified. This study aimed to evaluate the association between the type of hypnotic and in-hospital fractures in older patients with neurocognitive disorders using a nationwide inpatient database.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we collected information on inpatients aged ≥65 years with neurocognitive disorders between April 2014 and March 2021. We examined trends in the prescription patterns of benzodiazepine drugs, Z-drugs, orexin receptor antagonists and melatonin receptor agonists. We also carried out a 1:4 matched case-control analysis of in-hospital fractures. The odds ratio of each hypnotic drug was estimated using a generalized estimating equation with adjustment for walking ability, comorbidities, osteoporosis, dialysis, selective serotonin reuptake inhibitor use and anti-dementia drug use.

RESULTS

The prescription of benzodiazepine hypnotics decreased and that of orexin receptor antagonists increased. This case-control analysis included 6832 patients with fractures and 23 463 controls. Ultrashort-acting benzodiazepines, short-acting benzodiazepines and Z-drugs were associated with an increased risk of bone fracture (odds ratio [95% confidence interval] 1.38 [1.08-1.77], 1.38 [1.27-1.50], 1.49 [1.37-1.61], respectively). Orexin receptor antagonists were not associated with an increased risk of bone fracture (1.07 [0.95-1.19]).

CONCLUSIONS

In contrast to other types of hypnotics, orexin receptor antagonists were not associated with in-hospital fractures in older patients with neurocognitive disorders. Geriatr Gerontol Int 2023; 23: 500-505.