Exploring Polypharmacy in Elderly Women after Myocardial Infarction

Primary prevention statin therapy in older adults

PURPOSE OF REVIEW

The purpose of this review is to assess the evidence for primary prevention statin treatment in older adults, within the context of the most recent guideline recommendations, while also highlighting important considerations for shared decision-making.

RECENT FINDINGS

As the average lifespan increases and the older adult population grows, the opportunity for prevention of morbidity and mortality from cardiovascular disease is magnified. Randomized trials and meta-analyses have demonstrated a clear benefit for primary prevention statin use through age 75, with uncertainty beyond that age. Despite these data supporting their use, current guidelines conflict in their statin treatment recommendations in those aged 70-75 years. Reflecting the paucity of evidence, the same guidelines are equivocal around primary prevention statins in those beyond age 75. Two large ongoing randomized trials (STAREE and PREVENTABLE) will provide additional insights into the treatment benefits and risks of primary prevention statins in the older adult population. In the meantime, a holistic approach in treatment decisions remains paramount for older patients.

SUMMARY

The benefits of primary prevention statin treatment are apparent through age 75, which is reflected in the current ACC/AHA and USPSTF recommendations. Ongoing trials will clarify the utility in those beyond age 75.

Correlates of Treatment and Disease Burden in People Living with HIV (PLHIV) in Italy

Treatment burden is a multidimensional concept, including several aspects of life of patients affected by chronic conditions. It has been poorly explored in people living with HIV (PLHIV). An online anonymous survey of PLHIV taking antiretroviral therapy (ART) was conducted, in order to investigate the self-reported correlates of disease burden. HIV Treatment and Diseases Burden (TDB) was investigated with a questionnaire containing 31 items in 7 domains. Respondents were stratified in high burden (H-TDB)/low burden (L-TDB) according to overall HIV TDB mean + 1 standard deviation. Factors associated with H-TDB has been evaluated with a logistic regression model. In total, 531 PLHIV completed the questionnaire. 99 PLHIV had a H-TDB (18.6%). PLHIV with H-TDB were younger (p < 0.001), less frequently on current two drug antiretroviral (ARV) regimens (p = 0.01) and more frequently with plasma HIV-RNA >50 copies/mL (p = 0.04). At multivariable regression analysis, younger age (aOR 1.43, 95%CI 1.14–1.80; p = 0.002), not fully treatment satisfaction (aOR 2.19, 95%CI 1.28–3.74; p = 0.004), the need of a more accurate dialogue with treating physician (aOR 2.29, 95%CI 1.21–4.36, p = 0.01) and a self-declared lower overall Health Status (aOR 1.75, 95%CI 1.33–2.32; p = 0.002) were all associated with a H-TDB. One out of five PLHIV showed a high level of treatment and disease burden. Younger age, not fully satisfaction with ART and need of interaction with a tailored health system should be taken into consideration as correlates of treatment and disease burden in a patient-centered approach, to reduce the negative impact that it can produce on the overall perceived health status of the person.

Comparing comorbidity measures and fatigue post myocardial infarction

PURPOSE/AIMS

The purpose of this study was to examine comorbidity measures that may relate to the symptom of fatigue post MI: self-reported comorbidities, medication-validated comorbidities, weighted comorbidities for fatigue, and number of comorbidities.

DESIGN

Using a cross sectional design, we interviewed a convenience sample of 98 adults, 65 and older, who were 6 to 8 months post myocardial infarction.

METHODS

Participants self-reported their comorbidities using a list of 23 comorbid conditions. All medications were visually inspected, and medications were reviewed by a geriatric pharmacist for a common side effect of fatigue. The Revised Piper Fatigue Scale was used to measure fatigue.

RESULTS

The mean age of the participants was 76 (SD = 6.3), and most of the sample were White (84%). Neither medication-validated comorbidities nor those medications with fatigue as a common side effect explained fatigue. When controlling for age, sex, and marital status, self-reported comorbidities explained 10% of the variance in fatigue (F (4, 93) = 2.65; p = 0.04). Having 5 or more self-reported comorbidities explained 7% of variance in fatigue scores (F (1, 96) = 7.53; p = 0.007).

CONCLUSION

Comorbidities are associated with fatigue post MI. Adults post MI with 5 or more comorbidities should be screened for fatigue.

Treatment Burden and Chronic Illness: Who is at Most Risk?

BACKGROUND

There is a need to ascertain the type and level of treatment burden experienced by people with co-morbidities. This is important to identify the characteristics of participants who are at most risk of treatment burden.

OBJECTIVE

The aim of this study is to identify the characteristics of participants who are at most risk of treatment burden.

METHODS

This cross-sectional study was part of a larger project and recruitment was conducted across four Australian regions: rural, semi-rural and metropolitan. Participants were asked about their treatment burden using an adapted version of a measure, which included the following five dimensions: medication, time and administrative, lifestyle change, social life and financial burden.

RESULTS

In total, 581 participants with various chronic health conditions reported a mean global treatment burden of 56.5 out of 150 (standard deviation = 34.5). Number of chronic conditions (β = .34, p < 0.01), age, (β = -.27, p < 0.01), the presence of an unpaid carer (β = .22, p < 0.001) and the presence of diabetes mellitus and other endocrine conditions (β = .13, p < 0.01) were significant predictors of overall treatment burden. For the five dimensions of treatment burden, social, medicine and administrative burden were predicted by the same cluster of variables: number of conditions, age, presence of an unpaid carer and diabetes. However, in addition to these variables, financial dimensions were also predicted by education level, ethnicity and health insurance. Educational level also influenced lifestyle burden.

CONCLUSION

A substantial proportion of community-dwelling adults with chronic conditions have considerable levels of treatment burden. Specifically, health professionals should provide greater focus on managing overall treatment burden for persons who are of young age, have an endocrine condition or an unpaid carer, or a combination of these factors.

Medication Burden of Treatment Using Oral Cancer Medications

Objective:

With the changes in healthcare, patients with cancer now have to assume greater responsibility for their own care. Oral cancer medications with complex regimens are now a part of cancer treatment. Patients have to manage these along with the management of medications for their other chronic illnesses. This results in medication burden as patients assume the self-management.

Methods:

This paper describes the treatment burdens that patients endured in a randomized, clinical trial examining adherence for patients on oral cancer medications. There were four categories of oral agents reported. Most of the diagnoses of the patients were solid tumors with breast, colorectal, renal, and gastrointestinal.

Results:

Patients had 1–4 pills/day for oral cancer medications as well as a number for comorbidity conditions (>3), for which they also took medications (10–11). In addition, patients had 3.7–5.9 symptoms and side effects. Patients on all categories except those on sex hormones had 49%–57% drug interruptions necessitating further medication burden.

Conclusions:

This study points out that patients taking oral agents have multiple medications for cancer and other comorbid conditions. The number of pills, times per day, and interruptions adds to the medication burden that patients’ experience. Further study is needed to determine strategies to assist the patients on oral cancer medications to reduce their medication burden.

'You say treatment, I say hard work': treatment burden among people with chronic illness and their carers in Australia

The aim of this study was to explore treatment burden among people with a variety of chronic conditions and comorbidities and their unpaid carers. The burden of living with ongoing chronic illness has been well established. However, the burden associated with proactively treating and managing chronic illness, commonly referred to as 'treatment burden', is less understood. This study helps to bridge this gap in our understanding by providing an in-depth analysis of qualitative data collected from a large sample of adults from diverse backgrounds and with various chronic conditions. Using semi-structured in-depth interviews, data were collected with a large sample of 97 participants that included a high representation of people from culturally and linguistically diverse backgrounds and indigenous populations across four regions of Australia. Interviews were conducted during May-October 2012, either face to face (n = 49) or over the telephone (n = 48) depending on the participant's preference and location. Data were analysed using an iterative thematic approach and the constant comparison method. The findings revealed four interrelated components of treatment burden: financial burden, time and travel burden, medication burden and healthcare access burden. However, financial burden was the most problematic component with the cost of treatment being significant for most people. Financial burden had a detrimental impact on a person's use of medication and also exacerbated other types of burden such as access to healthcare services and the time and travel associated with treatment. The four components of treatment burden operated in a cyclical manner and although treatment burden was objective in some ways (number of medications, and time to access treatment), it was also a subjective experience. Overall, this study underscores the urgent need for healthcare professionals to identify patients overwhelmed by their treatment and develop 'individualised' treatment options to alleviate treatment burden.

Treatment burden among people with chronic illness: what are consumer health organizations saying?

OBJECTIVES

To explore the perspectives of consumer health organizations about the burden of chronic illness and multiple treatment regimens experienced by the consumers they represent.

METHODS

In-depth interviews (n = 15) were conducted with senior representatives from peak Australian consumer health organizations representing diabetes, asthma, cardiovascular disease, cancer, musculoskeletal illness and mental health.

RESULTS

Medication burden, which included aspects such as multiple medications, side effects, stigma and adverse events resulting from medication use, emerged as the most significant and prevalent theme. Carer burden and the negative impact of financial burden was widely discussed, particularly for low-income earners with claims that these consumers were forced to prioritise medications according to how effective they perceived them to be. Time taken to learn about treatment, administer, and monitor or travel to obtain treatment also emerged as being burdensome, however, difficulty accessing treatment was considered to be particularly burdensome. The disjointed nature of care among healthcare services was thought to create a sense of confusion and distress.

DISCUSSION

Many of the issues discussed by participants corroborated existing research, underscoring the complementary provider, and advocacy role of these organisations in mitigating treatment burden for people with chronic illness.

Burden of treatment for chronic illness: a concept analysis and review of the literature

CONTEXT

Treatment burden, the burden associated with the treatment and management of chronic illness, has not yet been well articulated.

OBJECTIVE

Using Rodgers' (1989, Journal of Advanced Nursing, 14, 330-335) method of concept analysis, this review describes the ways in which treatment burden has been conceptualized to define the concept and to develop a framework for understanding its attributes, antecedents and consequences.

METHODS

Leading databases were searched electronically between the years 2002 and 2011. To ensure the review focused on actual observations of the concept of interest, articles that did not measure treatment burden (either qualitatively or quantitatively) were excluded. An inductive approach was used to identify themes related to the concept of treatment burden.

MAIN RESULTS

Thirty articles, identified from 1557 abstracts, were included in the review. The attributes of treatment burden include burden as a dynamic process, as a multidimensional concept, and comprising of both subjective and objective elements. Prominent predisposing factors (antecedents) include the person's age and gender, their family circumstances, possible comorbidity, high use of medications, characteristics of treatment and their relationship with their health-care provider. The most dominant consequences are poor health and well-being, non-adherence to treatment, ineffective resource use and burden on significant others. Furthermore, many of these consequences can also become antecedents, reflecting the cyclic and dynamic nature of treatment burden.

CONCLUSION

The findings underscore the need for researchers and health-care professionals to engage in collaborative discussions and make cooperative efforts to help alleviate treatment burden and tailor treatment regimens to the realities of people's daily lives.

Polypharmacy and malnutrition

PURPOSE OF REVIEW

Malnutrition and polypharmacy increase with age and polymorbidity and their relationship is based on a number of mechanisms. The occurrence of malnutrition in both in-patients and out-patients and its dependence on polymorbidity and age are well known, but the interrelation of polypharmacy and malnutrition has been far less investigated. The countries with the highest occurrence of polypharmacy in Europe include the Czech Republic and Finland, whereas the lowest prevalence of polypharmacy is found in Norway and the Netherlands.

RECENT FINDINGS

The occurrence, consequences and mutual relationship of malnutrition and polypharmacy are described. Up-to-date knowledge regarding the influence of drugs on nutritional status is summarized.

SUMMARY

The effect of polypharmacy on nutrition is suggested from the observations that problems with nutrition occur mostly in elderly patients, and that such patients are more frequently subject to polypharmacy. It is known that about 65% of hospitalized patients have a worse nutritional status than their healthy contemporaries. A worsened nutritional status may adversely influence the process of treatment.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.