The association between polypharmacy and cognitive ability in older adults: A national cohort study

Polypharmacy and Mild Cognitive Impairment in Older Adults: A 3-year Study of DO-HEALTH

OBJECTIVE

To examine the association between polypharmacy and mild cognitive impairment (MCI) at baseline and over 3 years in community-dwelling older adults.

DESIGN

Observational analysis of the DO-HEALTH trial.

SETTING AND PARTICIPANTS

Community-dwelling adults aged ≥70 years with good cognitive function and without major diseases at baseline.

METHODS

Main exposure was polypharmacy at baseline (≥5 medications). The outcome was MCI (Montreal Cognitive Assessment [MoCA] score <26), assessed at baseline and years 1, 2, and 3. Logistic regression and generalized estimating equations (GEEs) for repeated binary outcomes were used for the cross-sectional and longitudinal analysis, respectively. Minimally adjusted models included age, sex, prior fall, study site, body mass index, and education. Fully adjusted models additionally adjusted for mental health and multimorbidity. GEE models also accounted for time and DO-HEALTH treatment effects. Sensitivity analysis used a stricter MCI definition (MoCA < 24).

RESULTS

A total of 2153 participants completed MoCA at baseline. Baseline MCI prevalence was higher in participants with polypharmacy compared with those with no polypharmacy (MCI < 26: 53.5% vs 46.5%; MCI < 24: 34.9% vs 17.2%). Polypharmacy was associated with greater MCI odds at baseline in the minimally adjusted models (MoCA < 26: odds ratio [OR], 1.32; 95% CI, 1.05-1.66; MoCA < 24: OR, 1.37; 95% CI, 1.06-1.79). Over 3 years, polypharmacy was associated with increased MCI odds in the minimally adjusted models (MoCA < 26: OR, 1.28; 95% CI, 1.08-1.52; MoCA < 24: OR, 1.33; 95% CI, 1.07-1.65). Notably, these associations were somewhat attenuated and nonsignificant after controlling for mental health and multimorbidity.

CONCLUSION AND IMPLICATIONS

Our findings suggest that MCI is more prevalent in older adults with polypharmacy compared with those without polypharmacy. Although polypharmacy was associated with MCI at baseline and over 3 years, these associations were attenuated by mental health and multimorbidity, suggesting that mental health and multimorbidity contribute to both polypharmacy and MCI.

Implementing psychosocial guidelines into specialized spinal cord injury rehabilitation services to strengthen person-centred health care: protocol for a mixed methods study

Background

Spinal cord injury (SCI) is a severe neurological disorder resulting in loss of movement and altered sensation with lifelong impacts on health, function, and social integration. Multidisciplinary SCI rehabilitation primarily focuses on enhancing function and independence while simultaneously managing secondary health conditions and providing psychosocial support. Therefore, a major goal in SCI rehabilitation should be strengthening patients' capacity to cope with and adjust to challenges they encounter. Using a mixed methods design, the primary aim of this study is to integrate psychosocial guidelines that promote psychological adjustment into SCI rehabilitation, and second, to evaluate facilitators and barriers to their successful implementation.

Methods

To determine perceived depth of knowledge, beliefs, and attitudes about psychosocial care, and usage of psychosocial guidelines, healthcare professionals in the three specialist SCI services in New South Wales, Australia will be invited to complete a baseline survey. Following the survey, semi-structured one-to-one interviews and focus groups will be conducted with healthcare professionals representing different health disciplines to understand the context and generate ideas about how best to integrate these guidelines into clinical practice. Based on the surveys, interviews, and focus groups, an implementation intervention employing educational strategies, structural, and nudge (behavioural change) approaches will be designed and implemented over a period of 18-months to facilitate integration of the guidelines into the SCI services. A post-intervention survey with healthcare workers will then be conducted. Focus groups from each SCI service, with representation across the different healthcare professions, will also be conducted to identify facilitators and barriers to implementing the guidelines. Success of implementation will be determined by analyzing any shifts in perceived knowledge, attitudes, and behaviour of staff and cultural/structural processes observed through comparing baseline and post-intervention qualitative and quantitative data. To capture lived experience insight, 10 patients with SCI currently undergoing rehabilitation will be interviewed.

Discussion

This study will establish the success of implementing psychosocial guidelines into three specialist SCI services. It is hypothesized that constructive changes will occur in the knowledge, attitudes, and behaviour of the SCI Unit healthcare professionals, leading to improved psychosocial practices and patient outcomes that will strengthen person-centred healthcare in SCI rehabilitation. This study has been retrospectively registered with the Australian New Zealand Clinical Trials Registry on the 7th of May 2024. The registration number is: ACTRN12624000581561.

Socioeconomic status and adherence to COVID-19 preventative measures in Australia: A national cohort study

ISSUE ADDRESSED

The uptake of recommended preventative measures is a critical concern for protecting the public against COVID-19 outbreaks and future pandemics. However, it is unclear to what extent COVID-19 preventative measures were followed in Australia. This study aims to determine adherence level to COVID-19 preventative measures in 2021, and whether these were associated with socioeconomic status (SES).

STUDY DESIGN

This was a national cross-sectional study using data from the Household Income and Labour Dynamics in Australia (HILDA) survey.

METHODS

This study included 15 457 community-dwelling adults (18 years or older) who participated in the 2021 wave of HILDA survey. SES was assessed by the Socio-Economic Index For Areas (SEIFA) score, split into quintiles. Outcomes included self-reported adherence to COVID-19 preventative measures (mask wearing, keeping distance, staying home; sum score range 3-15) and COVID-19 status (yes/no). Linear and logistic regression were used accordingly to assess the association between SES and the sum score of adherence to COVID-19 measures, and COVID-19 vaccination status.

RESULTS

Adherence to COVID-19 preventative measures and uptake of COVID-19 vaccine in Australia in 2021 were moderate (between 60% and 70%). Regression models showed higher SES was associated with a slightly higher score of adherence (β = .08, 95% CI = .04-.12) and a higher likelihood of self-reporting receiving COVID-19 vaccination (OR 1.27, 95% CI = 1.23-1.31).

CONCLUSION

SES was positively associated with the level of adherence to COVID-19 preventative measures and the probability of receiving COVID-19 vaccine. The findings of this study highlight the potential benefits of considering SES, particularly its impact on equity and access, when designing an educational program or awareness campaign in times of crisis. SO WHAT?: The findings of this study highlight the importance of considering SES when designing an educational program or an awareness campaign in times of crisis.

Chronic polypharmacy, monotherapy, and deprescribing: Understanding complex effects on the hepatic proteome of aging mice

Polypharmacy (use of ≥5 concurrent medications) is highly prevalent among older adults to manage chronic diseases and is linked to adverse geriatric outcomes, including physical and cognitive functional impairments, falls, frailty, hospitalization, and mortality. Deprescribing (withdrawal) is a potential strategy to manage polypharmacy. The broad molecular changes by which polypharmacy causes harm and deprescribing may be beneficial are unknown and unfeasible to study rigorously in tissue from geriatric patients. Therefore, in a randomized controlled trial, we administered therapeutic doses of commonly used chronic medications (oxycodone, oxybutynin, citalopram, simvastatin, or metoprolol) as monotherapy or concurrently (polypharmacy) from middle-age (12 months) to old-age (26 months) to male C57BL/6J (B6) mice and deprescribed (gradually withdrew) treatments in a subset from age 21 months. We compared drug-related hepatic effects by applying proteomics along with transcriptomics and histology. We found that monotherapy effects on hepatic proteomics were limited but significant changes were seen with polypharmacy (93% unique to polypharmacy). Polypharmacy altered the hepatic expression of proteins involved in immunity, and in drug, cholesterol, and amino acid metabolism, accompanied by higher serum drug levels than monotherapies. Deprescribing not only reversed some effects but also caused irreversible and novel changes in the hepatic proteome. Furthermore, our study identified several hepatic protein co-expressed modules that are associated with clinically relevant adverse geriatric outcomes, such as mobility, frailty, and activities of daily living. This study highlights the complex molecular changes following aging, chronic polypharmacy, and deprescribing. Further exploration of these mechanistic pathways may inform management of polypharmacy and deprescribing in older adults.

Association between polypharmacy and cognitive impairment in older adults: A systematic review and meta-analysis

OBJECTIVE

This meta-analysis explored the relationship between polypharmacy and cognitive impairment in older adults.

METHODS

We systematically searched for observational studies on polypharmacy and cognitive impairment in the Cochrane Library, PubMed, Web of Science, Embase, and CINAHL databases and performed meta-analysis to pool the study results using fixed- or random-effects models. The quality of evidence was assessed using the Grading of Recommendations, Assessment Development, and Evaluation system.

RESULTS

Twenty-seven studies involving 124,452,121 older adults aged >60 years were included. These studies showed that the risk of cognitive impairment was significantly increased in older adults with polypharmacy (≥5 medications) (OR = 1.39, 95% CI: 1.23-1.58, P < 0.001) and in those with excessive polypharmacy (≥10 medications) (OR = 1.51, 95% CI: 1.01-2.25, P = 0.042).

CONCLUSION

This study suggests a potential association between polypharmacy and cognitive impairment in older adults. However, the causal relationship requires further verification.

Medication burden and anticholinergic use are associated with overt HE in individuals with cirrhosis

BACKGROUND

Polypharmacy and anticholinergic medications are associated with cognitive decline in elderly populations. Although several medications have been associated with HE, associations between medication burden, anticholinergics, and HE have not been explored. We examined medication burden and anticholinergics in patients with cirrhosis and their associations with HE-related hospitalization.

METHODS

We conducted a retrospective cohort study of patients aged 18-80 with cirrhosis seen in hepatology clinics during 2019. The number of chronic medications (medication burden) and anticholinergic use were recorded. The primary outcome was HE-related hospitalization.

RESULTS

A total of 1039 patients were followed for a median of 840 days. Thirty-seven percent had a history of HE, and 9.8% had an HE-related hospitalization during follow-up. The mean number of chronic medications was 6.1 ± 4.3. Increasing medication burden was associated with HE-related hospitalizations in univariable (HR: 1.09, 95% CI: 1.05-1.12) and multivariable (HR: 1.07, 95% CI: 1.03-1.11) models. This relationship was maintained in those with baseline HE but not in those without baseline HE. Twenty-one percent were taking an anticholinergic medication. Anticholinergic exposure was associated with increased HE-related hospitalizations in both univariable (HR: 1.68, 95% CI: 1.09-2.57) and multivariable (HR: 1.71, 95% CI: 1.11-2.63) models. This relationship was maintained in those with baseline HE but not in those without baseline HE.

CONCLUSIONS

Anticholinergic use and medication burden are both associated with HE-related hospitalizations, particularly in those with a history of HE. Special considerations to limit anticholinergics and minimize overall medication burden should be tested for potential benefit in this population.

Polypharmacy and Associated Health Outcomes in the PARI-HD Study

Background

A growing body of evidence points to potential risks associated with polypharmacy (using ≥5 medications) in older adults, but most evidence is derived from studies where racial and ethnic minorities remain underrepresented among research participants.

Objective

Investigate the association between polypharmacy and cognitive function, subjective health state, frailty, and falls in Hispanic older adults.

Methods

Panama Aging Research Initiative-Health Disparities (PARI-HD) is a community-based cohort study of older adults free of dementia at baseline. Cognitive function was measured with a neuropsychological test battery. Frailty assessment was based on the Fried criteria. Subjective health state and falls were self-reported. Linear and multinomial logistic regression analyses were used to examine association.

Results

Baseline evaluations of 468 individuals with a mean age of 69.9 years (SD = 6.8) were included. The median number of medications was 2 (IQR: 1-4); the rate of polypharmacy was 19.7% (95% confidence interval [CI] = 16.1-23.3). Polypharmacy was inversely associated with self-rated overall health (b =-5.89, p < 0.01). Polypharmacy users had 2.3 times higher odds of reporting two or more falls in the previous 12 months (odds ratio [OR] = 2.31, 95% CI = 1.06-5.04). Polypharmacy was independently associated with Fried's criteria for pre-frailty (OR = 2.90, 95% CI = 1.36-5.96) and frailty (OR = 5.14, 95% CI = 1.83-14.42). Polypharmacy was not associated with cognitive impairment.

Conclusions

These findings illustrate the potential risks associated with polypharmacy among older adults in Panama and may inform interventions to improve health outcomes in this population.

Polypharmacy, Unintended Consequences, and Impact of Lifestyle Medicine

The coexistence of more than one chronic condition is called multimorbidity. Polypharmacy is defined as the use of multiple medicines with the typical definition stating 5 or more medications. There are several risk factors associated with polypharmacy and it may occur due to many reasons. Polypharmacy has been associated with multiple negative outcomes including nonadherence to treatment, side effects, drug-drug or disease interactions, falls, fractures, impairments-physical and cognitive, and medical errors. Strategies to assess and address polypharmacy are necessary, and lifestyle medicine is shown to play a role in improving health outcomes even when polypharmacy exists.

Six-item cognitive impairment test (6-CIT)'s accuracy as a cognitive screening tool: best cut-off levels in emergency department setting

Background

Nowadays, elderly patients represent a significant number of accesses to the Emergency Department (ED). Working rhythms do not allow to perform complete cognitive analysis, which would, however, be useful for the health care. This study aims to define the optimal cut-off values of the six-item Cognitive Impairment Test (6-CIT) as a cognitive screening tool in ED.

Methods

This study included 215 subjects, evaluated at the Emergency Department of the University Hospital of Monserrato, Cagliari, Italy, from July to December 2021. The accuracy of 6-CIT as a cognitive screening tool was assessed by comparison with Mini Mental State Examination (MMSE).

Results

The correlation coefficient between the two tests was -0.836 (CI: -0.87 to -0.79; p < 0.0001), and 6-CIT showed AUC = 0.947 (CI: 0.908-0.973; p < 0.0001). The 8/9 6-CIT cut-off score presented 86.76% sensitivity (CI: 76.4-93.8) and 91.84% specificity (CI: 86.2-95.7), and Youden index for this score was 0.786.

Conclusion

Our study demonstrates that 6-CIT is a reliable cognitive screening tool in ED, offering excellent sensitivity and specificity with a 8/9 points cut-off score.

Attitude towards deprescribing and its association with frailty and complexity of medication regimen: A survey of older inpatients in a district health board in New Zealand

BACKGROUND

Older inpatients, particularly those with frailty, have increased exposure to complex medication regimens. It is not known whether frailty and complexity of medication regimens influence attitudes toward deprescribing. This study aimed to investigate (1) older inpatients' attitudes toward deprescribing; (2) if frailty and complexity of medication regimen influence attitudes and willingness to deprescribe - a relationship that has not been investigated in previous studies.

METHODS

In this cross-sectional study, older adults (≥ 65 years) recruited from general medicine and geriatric services in a New Zealand hospital completed the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Hospital frailty risk score (HFRS) was calculated using diagnostic codes and other relevant information present at the time of index hospital admission; higher scores indicate higher frailty risk. Medication regimen complexity was quantified using the medication regimen complexity index (MRCI); higher scores indicate greater complexity. Logistic regression analysis was used to identify predictors of attitudes and willingness to deprescribe.

RESULTS

A total of 222 patients were included in the study, the median age was 83 years and 63% were female. One in two patients reported feeling they were taking too many medications, and 1 in 5 considered their medications burdensome. Almost 3 in 4 (73%) wanted to be involved in decision-making about their medications, and 4 in 5 (84%) were willing to stop one or more of their medications if their prescriber said it was possible. Patients with higher MRCI had increased self-reported medication burden (adjusted odds ratio (AOR) 2.6, 95% CI 1.29, 5.29) and were more interested in being involved in decision-making about their medications (AOR 1.8, CI 0.99, 3.42) than those with lower MRCI. Patients with moderate HFRS had lower odds of willingness to deprescribe (AOR 0.45, CI 0.22,0.92) compared to the low-risk group. Female patients had a lower desire to be involved in decision-making. The oldest old age group( > 80 years) had lower self-reported medication burden and were less likely to want to try stopping their medications.

CONCLUSION

Most older inpatients wanted to be involved in decision-making about their medications and were willing to stop one or more medications if proposed by their prescriber. Medication complexity and frailty status influence patients' attitudes toward deprescribing and thus should be taken into consideration when making deprescribing decisions. Further research is needed to investigate the relationship between frailty and the complexity of medication regimens.

Microbiome First Medicine in Health and Safety

Microbiome First Medicine is a suggested 21st century healthcare paradigm that prioritizes the entire human, the human superorganism, beginning with the microbiome. To date, much of medicine has protected and treated patients as if they were a single species. This has resulted in unintended damage to the microbiome and an epidemic of chronic disorders [e.g., noncommunicable diseases and conditions (NCDs)]. Along with NCDs came loss of colonization resistance, increased susceptibility to infectious diseases, and increasing multimorbidity and polypharmacy over the life course. To move toward sustainable healthcare, the human microbiome needs to be front and center. This paper presents microbiome-human physiology from the view of systems biology regulation. It also details the ongoing NCD epidemic including the role of existing drugs and other factors that damage the human microbiome. Examples are provided for two entryway NCDs, asthma and obesity, regarding their extensive network of comorbid NCDs. Finally, the challenges of ensuring safety for the microbiome are detailed. Under Microbiome-First Medicine and considering the importance of keystone bacteria and critical windows of development, changes in even a few microbiota-prioritized medical decisions could make a significant difference in health across the life course.