Associations between polypharmacy and treatment intensity for hypertension and diabetes: a cross-sectional study of nursing home patients in British Columbia, Canada

Control Level of Type 2 Diabetes Mellitus in the Elderly Is Associated with Polypharmacy, Accompanied Comorbidities, and Various Increased Risks According to the Beers Criteria

Comorbidity rates in the geriatric population have increased because of rising life expectancy; thus, patients have had to use more medications. Type 2 diabetes mellitus, one of the most common diseases, may influence the number of drugs used in geriatric patients. The present study was designed to investigate the association between the level of type 2 DM and polypharmacy. Fifty patients with type 2 diabetes over the age of 65 were included according to the inclusion criteria; 23 were well-controlled and 27 had poorly controlled diabetes. The groups were similar in terms of age, sex, WBC, Hb, Plt, AST, ALT, serum creatinine, fasting glucose, and eGFR levels. Patients with HbA1c values above 7.5 were classified as poorly controlled diabetes patients, and those below were considered well-controlled diabetes patients and were evaluated for inappropriate medication use. The number of medications used daily by the cases (p < 0.001), the number of concomitant diseases (p = 0.001), and the number of increased risks according to the Beers Criteria (p = 0.02) were observed to be high in poorly controlled type 2 diabetes mellitus subjects. HbA1c levels were related to the number of medications (r = 0.4, p = 0.004), comorbidities (r = 0.28, p = 0.04), and the number of increased risks according to the Beers Criteria (r = 0.31, p = 0.014). In conclusion, the number of medications used in patients with poorly controlled type 2 diabetes mellitus was found to be more elevated than in individuals with well-controlled type 2 diabetes mellitus. The HbA1c values varied among patients regarding polypharmacy, comorbidities, and increased risks according to the Beers Criteria.

Real-World Hemoglobin A1c Changes, Prescribing Provider Types, and Medication Dose Among Patients with Type 2 Diabetes Mellitus Initiating Treatment with Oral Semaglutide

INTRODUCTION

Given the lack of real-world data on oral semaglutide use outside clinical trials, the purpose of this study was to describe dose, prescriber specialty, and change in hemoglobin A1c (HbA1c) after 6 months of oral semaglutide treatment for patients with type 2 diabetes mellitus (T2DM).

METHODS

This was a retrospective study among adult patients with T2DM with ≥ 1 claim for oral semaglutide between November 1, 2019`1-June 30, 2020. Patients had continuous health plan enrollment ≥ 12 months prior to (pre-index) and ≥ 6 months following (post-index) the date of the first oral semaglutide claim (index). Dose at initiation and specialty of the prescribing provider were captured. Change in HbA1c between the last post- and pre-index HbA1c measurement was calculated. Patients were stratified by pre-index HbA1c ≥ 9% (poorly controlled) and HbA1c < 9%.

RESULTS

A total of 744 HbA1c < 9% and 268 poorly controlled patients were included in the study. Most patients had an initial oral semaglutide dose of 7 mg (49.3%) or 3 mg (42.9%), prescribed most frequently by a primary care provider (27.8%). Mean HbA1c reduction was 0.8% (p < 0.001). Patients with poorly controlled T2DM had greater HbA1c reductions than patients with HbA1c < 9% (2.0% versus 0.4%, p < 0.001). Patients persistent with oral semaglutide (≥ 90 days continuous treatment) had a mean HbA1c reduction of 0.9% (p < 0.001); persistent patients with poorly controlled T2DM had a mean reduction of 2.5%.

CONCLUSIONS

Patients with T2DM in this study experienced significant reductions in HbA1c within 6 months following initiation of oral semaglutide. Patients with a higher starting HbA1c experienced greater HbA1c reductions. The initial dose of oral semaglutide was higher than prescribing instructions indicated for more than half of the study patients.

Current Understanding of Sodium N-(8-[2-Hydroxylbenzoyl] Amino) Caprylate (SNAC) as an Absorption Enhancer: The Oral Semaglutide Experience

Oral administration of peptide therapeutics faces challenges because of the distinct environment of the gastrointestinal tract. An oral formulation of semaglutide, a glucagon-like peptide 1 receptor agonist, was approved by the U.S. Food and Drug Administration in 2019 as a peptide therapy for the treatment of type 2 diabetes. Oral semaglutide uses sodium N-(8-[2-hydroxybenzoyl] amino) caprylate (SNAC) technology to enhance the absorption of semaglutide in the stomach and protect it from degradation by gastric enzymes. This article presents a summary of studies investigating SNAC technology as an absorption enhancer for a number of molecules and, in particular, explores how SNAC, once coformulated with oral semaglutide, facilitates increased absorption and bioavailability. Practical advice and dispensing information for pharmacists is also provided.

Evaluation of the impact of vindoline, an active components of Catharanthus roseus, on rat hepatic cytochrome P450 enzymes by using a cocktail of probe drugs

The objection of this study was to investigate the effects of vindoline(VDL) on the cytochrome P450 (CYP 450) isoforms (CYP1A2, 2B, 2C11, 2D1 and 3A) in rats. Firstly, the rats were randomly divided into VDL pretreatment group and blank group, each group had six rats. VDL pretreatment group was administrated VDL (20 mg·kg-1) by oral gavage for fifteen days consecutively, and the equivalent CMC-Na solution without VDL was given to the blank group by gavage. Secondly, a cocktail of caffeine, bupropion, diclofenac, dextromethorphan and midazolam was then administered on the sixteenth day. Finally, blood samples were collected at the specified time point, and the plasma concentration of the probe drug was determined by UHPLC-QTOF-MS/MS. The effects of VDL on the activity of these CYP enzymes in rats were evaluated by pharmacokinetic parameters. VDL pretreatment group compared with the blank group, accelerated the metabolism of diclofenac, and weakened the metabolism of caffeine. These results suggested that VDL could induce the activity of CYP2C11, and inhibits the activity of CYP1A2, but had no significant effects on CYP2B, CYP2D1 and CYP3A. The results in this study can provide beneficial information for the later clinical application of VDL.

Changes in chronic disease medications after admission to a Geriatric Health Services Facility: A multi-center prospective cohort study

Older adults often receive polypharmacy, including some medications for chronic diseases. Nutritional management after admission to a nursing home may enable to deprescribe some chronic disease medications. This study aimed to investigate the status of deprescribing of chronic disease medications among nursing home residents, and to assess the appropriateness based on changes of laboratory test values and nutritional status. A multi-center prospective cohort study was conducted in 6 Geriatric Health Services Facilities, a major type of nursing homes in Japan. Newly admitted residents aged ≥ 65 years who took ≥1 medication for hypertension, diabetes, or dyslipidemia at admission were recruited. Participants who stayed for 3 months were included in the analysis. Medications at admission and 3 months after admission and situations for deprescribing were investigated. Changes in body mass index, blood pressure, laboratory tests (e.g., cholesterol and hemoglobin A1c levels), energy intake, and International Classification of Functioning, Disability and Health staging were evaluated. Sixty-nine participants (68% female, 62% aged ≥ 85 years) were included. At admission, 60 participants had medications for hypertension, 29 for dyslipidemia, and 13 for diabetes. Those receiving lipid-modifying drugs (mainly statins) decreased from 29 to 21 (72%; P = .008), since their cholesterol levels was within the normal range or was low at admission, and they had no history of cardiovascular events. However, there were no statistically significant changes in the frequencies of antihypertensive drugs (60 to 55; 92%; P = .063) or antidiabetic drugs (13 to 12; 92%; P = 1.000). During the 3-month observation, body mass index and diastolic blood pressure decreased, while energy intake and serum albumin level increased. Nutritional management after admission to a ROKEN may facilitate appropriate deprescribing of lipid-modifying drugs, by offseting the effects of discontinuation of these drugs.

Effects of Polypharmacy in Elderly Diabetic Patients: A Review

Diabetes is a chronic condition brought on by either insufficient insulin production by the pancreas or inefficient insulin utilization by the body or both. A hormone called insulin controls blood sugar. Multiple co-morbidities can arise as a result of the progressive nature of diabetes, necessitating the use of numerous medications. As one or more medications may be used to treat each ailment, the older population with multimorbidity frequently uses many medications, also known as polypharmacy. Due to polypharmacy, harmful medication interactions, and food-drug interactions can occur. Because of the numerous co-morbidities that already exist, there is an increasing tendency of prescribing polypharmacy.

Prevalence and impact of polypharmacy in older patients with type 2 diabetes

BACKGROUND

Polypharmacy is a prevalent condition in older adults, especially those with multiple chronic diseases, and has been largely associated with adverse outcomes, including disability, hospitalizations, and death.

AIMS

This systematic review focused on diabetes and aimed to investigate the prevalence and impact of polypharmacy in older adults affected by such disease.

METHODS

Observational (either cross-sectional or longitudinal) or experimental studies investigating the frequency and impact of polypharmacy in older adults with diabetes were identified from scientific databases and grey literature until August 2021. The prevalence and the 95% Confidence Interval (95% CI) of polypharmacy in older people with diabetes were summarized by a random-effects meta-analysis.

RESULTS

From a total of 1465 records, 9 were selected for the qualitative synthesis, and 8 for the quantitative synthesis. Most studies defined polypharmacy using a cut-off for the minimum number of medications ranging from 4 to 6 drugs/day. The pooled prevalence of polypharmacy in older people with diabetes was 64% (95% CI 45-80%). Considering studies that used the same definition of polypharmacy (i.e. ≥ 5 drugs/day), the pooled prevalence was 50% (95% CI 37-63%). The between-studies heterogeneity was high. Across the selected studies, polypharmacy seemed to negatively influence both diabetes-specific (poor glycemic control and risk of hypoglycemia) and health-related (risk of incident falls, syncope, hospitalization, and death) outcomes.

CONCLUSION

This systematic review confirms the high prevalence of polypharmacy in older people with diabetes and its strong impact on several health-related outcomes, including mortality. These results strengthen the need to improve care strategies for management of these patients.

New Diagnostic Criteria for Overmedication in Systemic Arterial Hypertension

BACKGROUND

Guidelines on managing arterial blood pressure have begun to include lower targets, despite the risk for overmedication-induced hypotension. Because there is no consensus as to what constitutes overmedication in the treatment of hypertension, we conducted a study to develop relevant diagnostic criteria.

METHODS

We used ambulatory monitoring during a 24-hour period to measure blood pressure in 567 patients with medication-controlled hypertension. We then divided this cohort into 3 groups. Group A (n = 413 [72.8%]) comprised patients in whom less than 10% of systolic blood pressure measurements were less than 100 mm Hg (no or mild hypotension). Group B (n = 154 [27.2%]) comprised patients in whom 10% or more of the measurements were less than 100 mm Hg, signifying overmedication. Group C comprised those patients in Group B in whom 20% or more of the measurements were less than 100 mm Hg (n = 74 [48.1%]; attributed to "accentuated" overmedication). Group C patients were prescribed significantly more antihypertensive drugs than were group A patients.

RESULTS

Our findings support a 2-part definition of overmedication in hypertension treatment: (1) mild overmedication, in which 10% or more but less than 20% of systolic blood pressure measurements are less than 100 mm Hg in the awake state and less than 90 mm Hg during sleep; and (2) accentuated overmedication, characterized by 20% or more of valid systolic blood pressure measurements less than 100 mm Hg in the awake state and less than 90 mm Hg during sleep, during a 24-hour period.

CONCLUSION

We think this guidance will help to avoid overmedicating and consequences such as fainting and falls when systolic blood pressure is too low.

Inappropriate use of clinical practices in Canada: a systematic review

Background:

Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.

Methods:

We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.

Results:

We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9).

Interpretation:

We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Overtreatment and undertreatment in a sample of elderly people with diabetes

AIMS

In older adults with type 2 diabetes (T2D), overtreatment remains prevalent and undertreatment ignored. The main objective is to estimate the prevalence and examine factors associated with potential overtreatment and undertreatment.

METHOD

Observational study conducted within an administrative database of older adults with T2D who registered in 2018 at the Portuguese Diabetes Association. Participants were categorized either as potentially overtreated (HbA1c ≤ 7.5%), appropriately on target (HbA1c ≥7.5 to ≤9%), or potentially undertreated (HbA1c > 9%).

RESULTS

The study included 444 participants: potential overtreatment and undertreatment were found in 60.5% and 12.6% of the study population. Taking the patients on target as a comparator, the group of potentially overtreated showed to be more men (61.3% vs 52.2%), less-obese (34.1% vs 39.2), higher cardiovascular diseases (13.7% vs 11%), peripheral vascular diseases (16.7% vs 12.8%), diabetic foot (10% vs 4.5%), and severe kidney disease (5.2% vs 4.5%). Conversely, the potentially undertreated participants were more women (64.2% vs 47.7%), obese (49% vs 39.2%), had more dyslipidemia (69% vs 63.1%), peripheral vascular disease (14.2% vs 12.8%), diabetic foot (8.9% vs 4.5%), and infections (14.2% vs 11.9%). The odds of potential overtreatment were mostly decreased by 59% of women, 73.5% in those with retinopathy, and 86.3% in insulin, 65.4% sulfonylureas, and 66.8% in SGLT2 inhibitors users. Contrariwise, an increase in the odds of potential undertreatment was more than 4.8 times higher in insulin, and more than 3.1 times higher in sulfonylureas users.

CONCLUSION

Potential overtreatment and undertreatment in older adults with T2D in routine clinical practice should guide the clinicians to balance the use of newer oral antidiabetic agents considering its safety profile regarding hypoglycemia.

Older Age, Polypharmacy, and Low Systolic Blood Pressure Are Associated With More Hypotension-Related Adverse Events in Patients With Type 2 Diabetes Treated With Antihypertensives

Background and Aims: Low systolic blood pressure (SBP) levels while being treated with antihypertensives may cause hypotension-related adverse events (hrAEs), especially in the elderly, women, and frail patients. We aimed to assess the association between the occurrence of hrAEs and low SBP levels, age, sex, and polypharmacy among patients with type 2 diabetes (T2D) treated with antihypertensives.

Methods: In this cohort study, we used the Groningen Initiative to ANalyse Type 2 diabetes Treatment (GIANTT) database which includes patients managed for T2D in primary care from the north of the Netherlands. Patients treated with ≥1 antihypertensive drug and ≥1 SBP measurement between 2012 and 2014 were included. The outcome was the presence of an hrAE, i.e. postural hypotension, dizziness, weakness/tiredness, and syncope in 90 days before or after the lowest recorded SBP level. Age (≥70 vs. <70 years), sex (women vs. men), polypharmacy (5–9 drugs or ≥10 drugs vs. <5 drugs), and SBP level (<130 or ≥130 mmHg) were included as determinants. Logistic regression analyses were conducted for age, sex and polypharmacy, including the SBP level and their interaction, adjusted for confounders. Odds ratios (OR) with 95% confidence intervals (CI) are presented.

Results: We included 21,119 patients, 49% of which were ≥70 years old, 52% were women, 57% had polypharmacy, 61% had an SBP level <130 mmHg and 5.4% experienced an hrAE. Patients with an SBP level <130 mmHg had a significantly higher occurrence of hrAEs than patients with a higher SBP level (6.2 vs. 4.0%; ORs 1.41, 95%CI 1.14–1.75, 1.43, 95%CI 1.17–1.76 and 1.33, 95%CI 1.06–1.67 by age, sex, and polypharmacy, respectively). Older patients (OR 1.29, 95%CI 1.02–1.64) and patients with polypharmacy (OR 5–9 drugs 1.27, 95%CI 1.00–1.62; OR ≥10 drugs 2.37, 95% CI 1.67–3.37) were more likely to experience an hrAE. The association with sex and the interactions between the determinants and SBP level were not significant.

Conclusion: Low SBP levels in patients with T2D treated with antihypertensives is associated with an increase in hrAEs. Older patients and those with polypharmacy are particularly at risk of hrAEs. Age, sex, and polypharmacy did not modify the risk of hrAEs associated with a low SBP level.

"I must, and I can live with that": a thematic analysis of patients' perspectives on polypharmacy and a digital decision support system for GPs

Background

To investigate patients’ perspectives on polypharmacy and the use of a digital decision support system to assist general practitioners (GPs) in performing medication reviews.

Methods

Qualitative interviews with patients or informal caregivers recruited from participants in a cluster-randomized controlled clinical trial (cRCT). The interviews were transcribed verbatim and analyzed using thematic analysis.

Results

We conducted 13 interviews and identified the following seven themes: the patients successfully integrated medication use in their everyday lives, used medication plans, had both good and bad personal experiences with their drugs, regarded their healthcare providers as the main source of medication-related information, discussed medication changes with their GPs, had trusting relationships with them, and viewed the use of digital decision support tools for medication reviews positively. No unwanted adverse effects were reported.

Conclusions

Despite drug-related problems, patients appeared to cope well with their medications. They also trusted their GPs, despite acknowledging polypharmacy to be a complex field for them. The use of a digital support system was appreciated and linked to the hope that reasons for selecting specific medication regimens would become more comprehensible. Further research with a more diverse sampling might add more patient perspectives.

Trial registration

ClinicalTrials.gov, NCT03430336. Registered on February 6, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01517-6.

Social Connection is Essential in Long-Term Care Homes: Considerations During COVID-19 and Beyond

COVID-19 has had a profound impact on long-term care (LTC) homes in Canada. But the measures put in place to control infection within LTC homes have also had devastating impacts on the health and well-being of residents through the effects on social connection. Here, we offer guiding principles to enable social connection and promote health and quality of life for LTC residents during COVID-19 and beyond. These principles were generated by a working group of the COVID-19 and Dementia Task Force, convened by the Alzheimer Society of Canada to identify the urgent and emerging issues raised by COVID-19 for Canadians with dementia.

Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review

OBJECTIVE

To investigate the prevalence, outcomes, and factors associated with potential glycemic overtreatment and undertreatment of type 2 diabetes mellitus (T2DM) in long-term care facilities (LTCFs).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Residents with T2DM and aged ≥60 years living in LTCFs.

MEASURES

Articles published between January 2000 and September 2020 were retrieved following a systematic search of MEDLINE, EMBASE, Cochrane Library, CINAHL plus, and gray literature. Inclusion criteria were the reporting of (1) potential overtreatment and undertreatment quantitatively defined (implicitly or explicitly) based on hemoglobin A1c (HbA1c) and/or blood glucose; (2) prevalence, outcomes, and associated factors of potential glycemic overtreatment and undertreatment; and (3) the study involved residents of LTCFs.

RESULTS

Fifteen studies were included. Prevalence of potential overtreatment (5%-86%, n = 15 studies) and undertreatment (1.4%-35%, n = 8 studies) varied widely among facilities and geographical locations, and according to definitions used. Prevalence of potential overtreatment was 16%-74% when defined as treatment with a glucose-lowering medication in a resident with ≥1 hypoglycemia risk factor or serious comorbidity, together with a HbA1c <7% (n = 10 studies). Potential undertreatment was commonly defined as residents on glucose-lowering medication having HbA1c >8.5% and the prevalence 1.4%-14.8% (n = 6 studies). No studies prospectively measured resident health outcomes from overtreatment and undertreatment. Potential overtreatment was positively associated with use of oral glucose-lowering medications, dementia diagnosis or dementia severity, and/or need for assistance with activities of daily living (n = 2 studies). Negative association was found between potential overtreatment and use of insulin/combined insulin and oral glucose-lowering medication. No studies reported factors associated with potential undertreatment.

CONCLUSIONS AND IMPLICATIONS

The prevalence of potential glycemic overtreatment and undertreatment varied widely among residents with T2DM depending on the definition(s) used in each study. Longitudinal studies examining associations between glycemic management and health outcomes, and the use of consensus definitions of overtreatment and undertreatment are required to establish findings about actual glycemic overtreatment and undertreatment in LTCFs.

Association between control of diabetes mellitus and polypharmacy at the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

PURPOSE

To determine whether desirable diabetes control is associated with polypharmacy and to evaluate potential drug interactions (DI) in participants with diabetes mellitus in the Brazilian Longitudinal Study on Adult Health (ELSA-Brasil).

METHODS

This cross-sectional study included 1418 participants with medical diagnosis of diabetes at study baseline (2008-2010). Polypharmacy was defined as the use of ≥5 drugs. We described the frequency of the most common pharmacological groups used by patients and the potential DI.The association between desirable diabetes control (normal A1c, blood pressure and lipid levels) and polypharmacy was investigated using logistic regression.

RESULTS

Most participants were men (52.5%), mean age 57.6 (SD 8.4) years, educated to the university level (39.4%), and self-reported as white (42.9%). In this study, 7.1% (n = 101) of participants had desirable control of diabetes, while 40.4% (n = 573) used polypharmacy, and this use was not significantly associated with better diabetes control (adjusted odds ratio (OR = 1.35 [95%CI 0.86-2.13] P = .19).The pharmacological groups most frequently used were oral antidiabetics followed by acetylsalicylic acid, angiotensin-converting enzyme inhibitors (ACE inhibitors) and statins.The prevalence of potentially mild, moderate and severe DI were, respectively, 2.5%, 14.7% and 0.9%; however, in the desirable control of DM group, these potential DI were related to comorbidity control.

CONCLUSION

Faced with the importance of achieving optimal control of diabetes and minimizing risks of potential DI, these results, which are in keeping with previous findings described in the literature, might indicate that guidelines for the patient-centered management of control of diabetes must be revised.

Polypharmacy, potentially serious clinically relevant drug-drug interactions, and inappropriate medicines in elderly people with type 2 diabetes and their impact on quality of life

The aim of the study is to investigate the patterns of polypharmacy, clinical-relevant drug-drug interactions (DDIs), and potentially inappropriate medicines (PIMs), and whether polypharmacy, potential serious clinically-relevant DDIs, or PIMs can be associated with low quality of life (QoL) index scores of older adults with type 2 diabetes (T2D). A cross-sectional study was conducted using data of 670 elderly T2D sub-cohort from a nationwide pharmacy-based intensive monitoring study of inception cohort of T2D in Portugal. 72.09% were found on polypharmacy (≥5 medicines). Participants on polypharmacy were mostly females (P = .0115); more obese (P = .0131); have more comorbid conditions (P < .0001); more diabetes complications (P < .0001); and use more of glucose lowering drugs (P = .0326); insulin (P < .0001); chronic medicines (P < .0001); and have higher diabetes duration (P = .0088) than those without polypharmacy. 10.59% of the participants were found to have potential serious clinically relevant DDIs. The most frequent drug-combinations were angiotensin-converting enzyme (ACE) inhibitors with angiotensin-receptor blockers (ARBs), aspirin with Selective serotonin reuptake inhibitors (SSRIs), and clopidogrel with calcium channel blockers. PIMs are found in 36.11% of the participants. The most common PIMs were benzodiazepines, long-acting sulfonylureas, and iron overdose. The adjusted multivariate models show that Polypharmacy, PIMs, and potential serious clinically relevant DDIs were associated with lower QoL index scores (OR 1.80 95% CI 1.15-2.82), (OR 1.57 95% CI 1.07-2.28), and (OR 1.34 95% CI 0.73-2.48) respectively. The study shows that polypharmacy, potential serious clinical-relevant DDIs, and PIMs may correlate with risk of reduced health related QoL outcome of older adults with T2D.

Prevalence and factors associated with frailty in hospitalized older patients

Background

Frailty is a multidimensional syndrome that leads to an increase of an age-related disorder of several physiological systems, and cognitive abilities decline. The aim of this study was to evaluate the prevalence of frailty among older persons in Belgium and we examined the factors associated with frailty with a principal focus en cognitive, dietary status, and inflammatory parameters.

Methods

A total of 124 participants (90 women, 34 men; age: mean ± SD: 85.9 ± 5.5 years) were studied, recruited from the Geriatrics department, Belgium. Nutritional, cognitive status and physical activity were assessed using Mini Mental State Examination score (MMSE), Mini Nutritional Assessment score (MNA), and Katz score, respectively. Frailty syndrome was evaluated using the modified Short Emergency Geriatric Assessment (SEGA) score. Medication and medical history were recorded. Analyzed biochemical parameters included C-reactive protein (CRP), complete blood count, blood creatinine, vitamin D level, and serum protein electrophoresis. According to SEGA score, participants were divided into non-frail (n = 19), frail (n = 25) and severely frail patients (n = 80).

Results

The SEGA score was inversely correlated with MMSE, MNA and Katz score. SEGA.

score was negatively correlated to albumin levels (r = − 0.30; p < 0.001) and positively correlated to CRP, polypharmacy and age (r = 0.28, r = 0.37, r = 0.33 and p < 0.01 respectively). Logistic regression showed a strong association between frailty, Katz score, dementia, polypharmacy and living in nursing home.

Conclusion

Our results provide useful information for understanding mechanisms of frailty. This will help to develop preventive strategies for the elderly at the pre-frailty stage.

Cardiometabolic diseases and active aging - polypharmacy in control

OBJECTIVES

To estimate the prevalence of cardiometabolic diseases and their association with polypharmacy in elderly people at the University of the Third Age (Portuguese acronym: UnATI).

METHODS

A cross-sectional, descriptive, analytical study with 121 elderly patients. The prevalence ratio, Pearson's Chi-square test and Fisher's exact test were used as measures of association.

RESULTS

At the mean age of 68.3, most elderly had at least one cardiometabolic disease (82.6%), of which hypertension was the most prevalent (71.1%), and consumed prescription drugs of continuous use (92.6%). Almost half of the elderly (48.2%) used combinations of drugs, which suggests a high cardiovascular risk. Polypharmacy due to prescription was observed in almost one-third (28.6%) of the sample, associated with the use of antihypertensives (p=0.004), antidiabetics (p=0.000) or lipid-lowering agents (p<0.000).

CONCLUSIONS

Clinical guidelines recommend changes in lifestyle, but increased pharmacotherapy prevails in practice, which increases the risk of adverse events, especially in old age.

Utilization of drugs for the management of cardiovascular diseases at intermediate care facilities for older adults in Japan

OBJECTIVES

No established approaches exist for the pharmacological management of cardiovascular diseases (CVDs) in residents of long-term care facilities (LTCFs). This study aimed to evaluate the use of drugs for CVD prevention and treatment (CVD-related drugs) in a major type of LTCF in Japan.

METHODS

This study included 1318 randomly selected residents at 349 intermediate care facilities for older adults (called Roken). Prescriptions were investigated at admission and two months after admission according to therapeutic categories. Logistic regression was used to identify residents' characteristics that were associated with prescriptions of CVD-related drugs.

RESULTS

Prescriptions of all types of drugs and CVD-related drugs decreased in 36 % and 16 % of residents, respectively. Half of the residents received antihypertensives, a quarter received antiplatelets and diuretics, whereas one-tenth received antidiabetics, oral anticoagulants, and lipid-modifying drugs. The prevalence of most of individual drug categories were similar among residents with different physical or cognitive function, except for fewer antihypertensive and lipid-modifying drugs in those with severe cognitive disability. Adjusted analyses for prescriptions at two months after admission revealed that bedridden residents were more likely to be prescribed diuretics but less likely to be prescribed antihypertensives, antiplatelets, or lipid-modifying drugs. Residents with severe cognitive disability were less likely to be prescribed antihypertensives or lipid-modifying drugs. A known history of cardiovascular events was associated with greater use of CVD-related drugs.

CONCLUSION

CVD-related drugs were commonly prescribed for Roken residents, including those with low physical and cognitive functions. Deprescribing may contribute to the optimization of pharmacotherapy in LTCF residents.

Hypertension Management in Nursing Homes: Review of Evidence and Considerations for Care

PURPOSE OF REVIEW

We sought to summarize recent evidence regarding optimal blood pressure (BP) treatment targets and antihypertensive regimen intensity for nursing home (NH) residents and similar older, complex patients with hypertension.

RECENT FINDINGS

Recent trials have demonstrated cardiovascular benefits from more intensive BP targets among ambulatory, less complex older adults, but generalizability to NH residents is questionable. Other trials have demonstrated that de-intensifying antihypertensives in frail, older patients is feasible, with no or modest increases in BP, but most have not assessed effects on patient-centered outcomes. Observational studies with patients more representative of NH residents suggest harms associated with more intensive BP treatment and reduction in fall risk associated with deintensification, but findings and potential for bias vary across studies. Randomized trials and rigorous observational studies examining effects of deintensified BP management on patient-centered outcomes in complex, older populations are needed to inform improved guidelines and treatment for NH residents.

Polypharmacy in Type 2 Diabetes Mellitus: Insights from an Internal Medicine Department

BACKGROUND AND OBJECTIVES

Polypharmacy heavily impacts the quality of life of patients worldwide. It is a necessary evil in many disorders, and especially in type 2 diabetes mellitus, as patients require treatment both for this condition and its related or unrelated comorbidities. Thus, we aimed to evaluate the use of polypharmacy in type 2 diabetes mellitus vs. non-diabetes patients.

MATERIALS AND METHODS

A cross-sectional retrospective observational study was conducted. We collected the medical records of patients hospitalized in the Internal Medicine Clinic of the Clinical Emergency Hospital of Bucharest, Romania, for a period of two months (01/01/2018-28/02/2018). Patients diagnosed with type 2 diabetes mellitus were included in the study group, whereas patients who were not diabetic were used as controls.

RESULTS

The study group consisted of 63 patients with type 2 diabetes mellitus (mean age 69.19 ± 9.67 years, range 46-89 years; 52.38% males). The control group included 63 non-diabetes patients (mean age 67.05 ± 14.40 years, range 42-93 years, 39.68% males). Diabetic patients had more comorbidities (10.35 ± 3.09 vs. 7.48 ± 3.59, p = 0.0001) and received more drugs (7.81 ± 2.23 vs. 5.33 ± 2.63, p = 0.0001) vs. non-diabetic counterparts. The mean number of drug-drug and food-drug interactions was higher in type 2 diabetes mellitus patients vs. controls: 8.86 ± 5.76 vs. 4.98 ± 5.04, p = 0.0003 (minor: 1.22 ± 1.42 vs. 1.27 ± 1.89; moderate: 7.08 ± 4.08 vs. 3.54 ± 3.77; major: 0.56 ± 0.74 vs. 0.37 ± 0.77) and 2.63 ± 1.08 vs. 2.19 ± 1.42 (p = 0.0457), respectively.

CONCLUSIONS

Polypharmacy should be an area of serious concern also in type 2 diabetes mellitus, especially in the elderly. In our study, type 2 diabetes mellitus patients received more drugs than their non-diabetes counterparts and were exposed to more drug-drug and food-drug interactions.

Association between polypharmacy and dementia - A systematic review and metaanalysis

Objective: The association between polypharmacy and dementia is controversial. This systematic review and meta-analysis aims to summarize existing literature concerning the association between polypharmacy and dementia. Methods: A systematic literature review was performed by searching the EMBASE, PubMed, Scopus and International Pharmaceutical Abstract databases using terms related to polypharmacy and dementia. A meta-analysis was performed using random effect models. Results: Seven studies were included in this meta-analysis. The included studies were of medium to high quality with a potential for publication bias. A strong association between polypharmacy and dementia was found (pooled adjusted risk ratio (aRR) = 1.30 (95% CI: 1.16-1.46), I² = 68%). Excessive polypharmacy was also strongly associated with dementia (pooled aRR = 1.52 (95% CI: 1.39-1.67), I² = 24%). Conclusion: Pooled risk estimates from this meta-analysis showed that polypharmacy was associated with dementia. Although the causality of the relationship cannot be concluded from this analysis, the finding encourages the use of multidimensional assessment tools for dementia that includes the number of medications as a component.

Association of Total Medication Burden With Intensive and Standard Blood Pressure Control and Clinical Outcomes: A Secondary Analysis of SPRINT

Total medication burden (antihypertensive and nonantihypertensive medications) may be associated with poor systolic blood pressure (SBP) control. We investigated the association of baseline medication burden and clinical outcomes and whether the effect of the SBP intervention varied according to baseline medication burden in SPRINT (Systolic Blood Pressure Intervention Trial). Participants were randomized to intensive or standard SBP goal (below 120 or 140 mm Hg, respectively); n=3769 participants with high baseline medication burden (≥5 medications) and n=5592 with low burden (<5 medications).

PRIMARY OUTCOME

differences in SBP.

SECONDARY OUTCOMES

8-item Morisky Medication Adherence Scale and modified Treatment Satisfaction Questionnaire for Medications measured at baseline and 12 months and incident cardiovascular disease events and serious adverse events throughout the trial. Participants in the intensive group with high versus low medication burden were less likely to achieve their SBP goal at 12 months (risk ratio, 0.91; 95% CI, 0.85-0.97) but not in the standard group (risk ratio, 0.98; 95% CI, 0.93-1.03; P_interaction<0.001). High medication burden was associated with increased cardiovascular disease events (hazard ratio, 1.39; 95% CI, 1.14-1.70) and serious adverse events (hazard ratio, 1.34; 95% CI, 1.24-1.45), but the effect of intensive versus standard treatment did not vary between medication burden groups (P_interaction>0.5). Medication burden had minimal association with adherence or satisfaction. High baseline medication burden was associated with worse intensive SBP control and higher rates of cardiovascular disease events and serious adverse events. The relative benefits and risks of intensive SBP goals were similar regardless of medication burden.

CLINICAL TRIAL REGISTRATION- URL

http://www.

CLINICALTRIALS

gov. Unique identifier: NCT01206062.

Prevalence and predictors of polypharmacy prescription among type 2 diabetes patients at a tertiary care department in Ningbo, China: A retrospective database study

Objectives

To determine the prevalence of polypharmacy prescription among type 2 diabetes (T2DM) patients at a tertiary care department in Ningbo, China, and to determine factors that independently predict this polypharmacy prescription.

Methods

A retrospective cross-sectional study was conducted using an existing computerised medical records database. This database was screened from 2012 to 2017 for adult patients with T2DM and parameters like prescribed medicines and socio-demographic, behavioural and other medical information. Polypharmacy prescription was defined as the simultaneous prescription of ≥5 medicines by the clinician at the time of discharge for daily usage by the patient as part of his/her long-term treatment plan.

Results

The study inclusion criteria were satisfied by 3370 T2DM patients. Over a 5-year period, 72.2% (n = 2432) of T2DM patients were prescribed polypharmacy. On an average, eight medicines were prescribed to them. The odds of polypharmacy prescription increased with patients’ age (18–39 years: 1; 40–59 years: OR 1.86, 95% CI 1.28–2.71; and ≥60 years: 2.42, 1.65–3.55), duration of T2DM (≤1 year: 1; >5–10 years: 1.70, 1.10–2.62; and >10 years: 2.55, 1.68–3.89), and length of hospital stay (≤5 days: 1; >5–10 days: 2.43, 1.86–3.17; and >10 days: 2.99, 2.24–3.99), and were higher in those with poor blood glucose level (2.09, 1.67–2.62) and with comorbidities like other endocrine, nutritional and metabolic diseases (2.24, 1.76–2.85), circulatory system diseases (4.35, 3.62–5.23), skin and subcutaneous tissue diseases (1.64, 1.04–2.59), and musculoskeletal system and connective tissue diseases (1.61, 1.27–2.03). The odds of polypharmacy prescription were lower in those with comorbidities like neoplasms (0.51, 0.36–0.70) and during pregnancy, childbirth and the puerperium (0.06, 0.01–0.49).

Conclusions

Around three fourth of T2DM patients at the tertiary care department were prescribed polypharmacy, and the predictors were identified. The study findings could be taken into consideration in future interventional studies aimed at supporting medicines optimisation (and deprescribing) among these patients.

Impact of pharmacotherapeutic education on medication adherence and adverse outcomes in patients with type 2 diabetes mellitus: a prospective, randomized study

AIM

To evaluate the impact of pharmacotherapeutic education on 30-day post-discharge medication adherence and adverse outcomes in patients with type 2 diabetes mellitus (T2DM).

METHODS

The prospective, randomized, single-center study was conducted at the Medical Department of University Hospital Dubrava, Zagreb, between April and June 2018. One hundred and thirty adult patients with T2DM who were discharged to the community were randomly assigned to either the intervention or the control group. Both groups during the hospital stay received the usual diabetes education. The intervention group received additional individual pre-discharge pharmacotherapeutic education about the discharge prescriptions. Medication adherence and occurrence of adverse outcomes (adverse drug reactions, readmission, emergency department visits, and death) were assessed at the follow-up visit, 30 days after discharge.

RESULTS

The number of adherent patients was significantly higher in the intervention group (57/64 [89.9%] vs 41/61 [67.2%]; χ2 test, P=0.003]. There was no significant difference between the groups in the number of patients who experienced adverse outcomes (31/64 [48.4%] vs 36/61 [59.0%]; χ2 test, P=0.236). However, higher frequencies of all adverse outcomes were consistently observed in the control group.

CONCLUSION

Pharmacotherapeutic education of patients with T2DM can significantly improve 30-day post-discharge medication adherence, without a significant reduction in adverse clinical outcomes. ClinicalTrial.gov identification number: NCT03438162.

Blood pressure management in older people: balancing the risks

Guidelines of arterial hypertension treatment based on individualised expected outcomes are not available for frail older persons. In this paper, we review the evidence, concerning management of arterial blood pressure (BP) in frail older patients. We focused on the best affordable methods for BP measurement; the age-related optimum BP; specific BP goals in agreement with the patients' general heath, frailty status, orthostatic and postprandial hypotension; balancing the benefits against risks of antihypertensive treatment. Lenient BP goals are generally recommended for older persons with moderate or severe frailty, multimorbidity and limited life expectancy. To this aim, there may be a need for deintensification of antihypertensive treatment.