Optimization of drug therapy in elderly individuals admitted to a geriatric unit

Prevalence of Polypharmacy in Elderly Population Worldwide: A Systematic Review and Meta-Analysis

BACKGROUND

Polypharmacy (PP) is common in elderly population and associated with some adverse clinical outcomes and increases healthcare burdens. We performed this systemic review and meta-analysis to estimate worldwide prevalence of PP and explore associated factors in the elderly.

METHODS

The PubMed, Web of Science, Cochrane Library, and Ovid EMBASE databases were searched for studies published until May 30, 2022. We included observational studies representative of general patients aged ≥60 in which PP was defined as multiple drugs ≥5. Studies were excluded if only a particular group of the elderly population (e.g., with diabetes) were included. The primary outcome was the prevalence of PP. Random-effect models were employed to estimate the overall or variable-specific pooled estimates of PP. Secondary outcomes were hyperpolypharmacy (HPP, defined as multiple drugs ≥10) and PP prevalence based on different study years, genders, locations, populations, and so forth.

RESULTS

We included 122 original observational studies with an overall population of 57 328 043 individuals in the meta-analysis. The overall prevalence of PP and HPP in the elderly population worldwide was 39.1% (95% confidence interval [CI], 35.5%-42.7%) and 13.3% (95% CI, 10.4%-16.5%), respectively. The prevalence of PP in Europe, Oceania, North America, Asia, and South America was 45.8% (95% CI, 41.5%-50.2%), 45.5% (95% CI, 26.7%-64.3%), 40.8% (95% CI, 29.8%-51.6%), 29.0% (95% CI, 20.0%-38.0%), and 28.4% (95% CI, 24.0%-32.8%), respectively (p < 0.01). Multivariate meta-regressions showed geographical regions of Europe or North America, age ≥70, and residence from nursing homes were independently associated with higher PP prevalence.

CONCLUSIONS

Nearly 40% of the elderly population is exposed to PP. The prevalence of PP is significantly higher in elderly individuals aged 70 or older, in developed regions and in nursing homes. It is important to focus on avoiding inappropriate PP in this population to address the growing burden of PP.

Providing information about medication changes upon discharge from a geriatric unit: the community healthcare professionals' point of view

INTRODUCTION

It is well known that polypharmacy is associated with adverse drug events. Accordingly, specialist geriatric units have to pay particular attention to the appropriateness of prescription and the withdrawal of potentially inappropriate medications. Even though community healthcare professionals are keen to received medication reconciliation results, the literature data show that the quality of communication between the hospital and the community needs to be improved.

OBJECTIVE

To assess community healthcare professionals' opinions about the receipt of medication reconciliation results when a patient is discharged from a specialist geriatric unit.

METHOD

We performed a qualitative study of general practitioners, community pharmacists and retirement home physicians recruited by phone in the Indre-et-Loire region of France. A grounded theory method was used to analyze interviews in multidisciplinary focus groups.

RESULTS

The 17 community healthcare professionals first explained why the receipt of medication reconciliation results was important to them: clarifying the course and outcomes of hospital stays and reducing the lack of dialogue with the hospital, so that the interviewees could provide the care expected of them. The interviewees also described mistrust of the hospital and uncertainty when the modifications were received; these two concepts accentuated each other over time. Lastly, they shared their opinions about the information provided by the hospital, which could improve patient safety and provide leverage for treatment changes but also constituted a burden.

PERSPECTIVES

Our participants provided novel feedback and insight, constituting the groundwork for an improved medication reconciliation form that could be evaluated in future research. Exploring hospital-based professionals' points of view might help to determine whether the requested changes in the medication reconciliation form are feasible and might provide a better understanding of community-to-hospital communication.

Discontinuation of Antidepressants in Older Adults: A Literature Review

Polypharmacy increases the risk of unbearable side effects, drug-drug interactions, and hospitalizations in geriatric patients. The iatrogenic risk of inadequate management of antidepressants is very important in this population. Therefore, primary care physicians and geriatricians have the responsibility of the optimization of antidepressants prescriptions. Our work is a literature review of the European and the international guidelines regarding the management of antidepressants. We reviewed the PubMed database and Google scholar for articles and reviews from 2015. We also screened relevant articles for more references and searched the web for available European guidelines relevant to our topic. We divided our findings into four main inquiries that are Indication, effectiveness, tolerability, and iatrogenic risks. Poor or absence of effectiveness should lead to a readjustment of the treatment plan. In case of unbearable side effects, antidepressants should be stopped, and alternative non-pharmacological therapies should be proposed. Doctors should look out for drug-drug interaction risks in this population and constantly adjust the prescription. Prescription of antidepressants is not always evidence based which leads to heavy iatrogenic consequences. We suggest a simple 4-questions-algorithm that aims to remind doctors of the basics of good practice and helps in the process of deprescribing an antidepressant in older adults.

Prevalence and Predictors of Potentially Inappropriate Medications Among Patients Aged ≥65 Years on Hospital Admissions in Kuwait

BACKGROUND

Potentially inappropriate medications are major health concerns for patients aged ≥65 years. To investigate the prevalence of potentially inappropriate medications, Beer's criteria can be used. We estimated the prevalence of potentially inappropriate medications prescription among patients aged ≥65 years admitted to Kuwait's largest hospital and identified the predictors of prescribing a potentially inappropriate medication.

METHODS

A cross-sectional study was conducted retrospectively using inpatient records from the medical department at the Hospital in Kuwait from 1 January 2019 to 31 December 2019. The latest version of Beer's criteria was used to identify potentially inappropriate medications in patients' medical records. Data were analyzed descriptively to estimate the prevalence of potentially inappropriate medications and to describe participant characteristics. The predictors of potentially inappropriate medications prescribing were determined using binary logistic regression.

RESULTS

A total of 423 medical records of patients were collected. The mean age of the patients admitted was 76 ± 7 years, and 222 of them (52.5%) were women. Upon hospital admission, potentially inappropriate medication was prevalent in 58.4% of patients. The most prevalent potentially inappropriate medications identified were proton pump inhibitors (27.3%), diuretics (21.5%), antipsychotic agents (9%), selective serotonin reuptake inhibitors (5%), and methyldopa (4%). Polypharmacy, Alzheimer's disease, depression, irritable bowel syndrome, hypothyroidism, chronic kidney disease were predictors of potentially inappropriate medications prescription.

CONCLUSION

A high prevalence of potentially inappropriate medication prescription was observed among patients aged ≥65 years admitted to a hospital in Kuwait. The most likely predictor of potentially inappropriate medication prescription was polypharmacy.

Reviewing Potentially Inappropriate Medication in Hospitalized Patients Over 65 Using Explicit Criteria: A Systematic Literature Review

Potentially inappropriate medication (PIM) is a primary health concern affecting the quality of life of patients over 65. PIM is associated with adverse drug reactions including falls, increased healthcare costs, health services utilization and hospital admissions. Various strategies, clinical guidelines and tools (explicit and implicit) have been developed to tackle this health concern. Despite these efforts, evidence still indicates a high prevalence of PIM in the older adult population. This systematic review explored the practice of using explicit tools to review PIM in hospitalized patients and examined the outcomes of PIM reduction. A literature search was conducted in several databases from their inception to 2019. Original studies that had an interventional element using explicit criteria detecting PIM in hospitalized patients over 65 were included. Descriptive narrative synthesis was used to analyze the included studies. The literature search yielded 6116 articles; 25 quantitative studies were included in this systematic literature review. Twenty were prospective studies and five were retrospective. Approximately, 15,500 patients were included in the review. Various healthcare professionals were involved in reviewing PIM including physicians and hospital pharmacists. Several tools were used to review PIM for hospitalized patients over 65, most frequently Beer’s criteria and the STOPP/START tool. The reduction of PIM ranged from 3.5% up to 87%. The most common PIM were benzodiazepines and antipsychotics. This systematic review showed promising outcomes in terms of improving patient outcomes. However, the reduction of PIM varied in the studies, raising the question of the variance between hospitals in the explicit tools used for review. Additional studies need to be conducted to further investigate the outcomes of reviewing PIM at different levels, as well as assessing the cost-effectiveness of using explicit tools in reducing PIM.

Persistence of Effect of Medication Review on Potentially Inappropriate Prescriptions in Older Patients Following Hospital Discharge

BACKGROUND

Potentially inappropriate prescriptions (PIPs) can lead to adverse drug reactions and should be avoided whenever possible.

OBJECTIVE

Our objective was to assess the PIP resumption rate 6 months after discharge from our geriatric unit and to compare it with data in the literature.

METHODS

This single-center observational study included patients aged ≥ 70 years with at least one PIP that had been stopped during hospitalization (according to Screening Tool for Older Persons Prescriptions [STOPP] and Screening Tool to Alert doctors to Right Treatment [START] criteria, version 2) between May 2018 and October 2018. We collected sociodemographic data, medication reconciliation data, and descriptive data during a comprehensive geriatric assessment. Each patient's medication history after discharge was determined in collaboration with their usual community pharmacist.

RESULTS

A total of 125 patients (females 70%, mean age 87.1 years) were included. Data for the admission and discharge medication reconciliations were available for 44 patients (35%). On admission, 121 of the 125 patients (97%) were taking cardiovascular medication. Of the 336 treatments withdrawn, 61 (18.2%) had been re-prescribed at 6 months post-discharge-including half within the first month. The most frequent STOPP criterion was lack of indication (32%), and the overall PIP resumption rate was 22%. According to the anatomical therapeutic chemical (ATC) classification, the main organ system affected by PIPs was the cardiovascular system (47%, with a resumption rate of 17%).

CONCLUSION

Our results highlighted a low PIP resumption rate at 6 months and showed that a collaborative medication review is associated with persistent medium-term medication changes.

[Usefulness of the summary of product characteristics as a tool to improve prescription in elderly patients]

BACKGROUND AND OBJECTIVE

The Drug Technical Data Sheet should contribute to a safe and effective use of medications in the elderly, providing accurate information on the prescription, on the possible benefits or risks of the medications, or failing that, communicating the lack of information on their use in this group. The aim of this article was to quantify the specific information for people over 65 years of age included in the data sheets of the drugs available in Spain, and enables an adequate prescription in this population.

MATERIALS AND METHODS

A multidisciplinary group reviewed all the Technical Data Sheets of drugs approved by the Spanish Agency for Medicines and Health Devices (AEMPS). The quality of the information was classified into 4 categories: information specifically referring to the population over 65 years old; information specifically referring to the population over 80 years old; recommendations not specific to the elderly; and specific information for the elderly.

RESULTS

A total of 1,462 Technical Sheets were reviewed, of which 48% had information regarding prescription in the elderly. Information on the use in patients over 80 years old was present in 1.23% of the sheets. Only 6.83% of all the sheets reviewed included specific recommendations for the elderly.

CONCLUSIONS

There is little specific information regarding prescription in the elderly in the technical data sheets of drugs prescribed/sold in Spain. To improve knowledge in this field, data must be provided in the sheets that are based on the scientific literature, clinical trials for the elderly, or pharmacovigilance studies focused on this population.

[Medication management of hypertension and heart failure in older patients: What happens to therapeutic changes after hospitalization?]

PURPOSE

The objective of this study was to objectivize if the cardiovascular therapeutic changes performed during hospitalization of older patients with hypertension and/or heart failure (HF), were maintained in ambulatory 3 month after hospitalization.

METHODS

This is a longitudinal study conducted in a geriatric unit. Patients over 65 years with hypertension and/or HF, who had at least one change in cardiovascular medicaton during hospitalization, and who accepted the 3-month follow-up were included in the longitudinal study. At admission, during hospitalization and 3 months after hospitalization data concerning cardiovascular medication were collected.

RESULTS

During hospitalization, 142 (73.6%) patients had at least one change in hypertension and/or HF medication. Overall, 249 changes were performed. Forty-one patients received follow-up at 3 months. At 3 months, therapeutic changes were maintained by 48.8% of the general practitioners (n=20 patients). For the rest, 41.5% of the patients had benefited from new therapeutic changes (28 changes for 10 patients) and 9.7% of the general practitioners (n=4 patients) had restored the initial prescription before hospitalization.

CONCLUSIONS

Medication review performed by geriatricians and pharmacists during hospitalization resulted in 249 changes. These changes aimed at limiting iatrogenic disease, by reducing overtreatment and potentially inappropriate prescriptions. Difficulties in the patient care continuity between the hospital and ambulatory setting have been identified.

Burden of Inappropriate Prescription of Direct Oral Anticoagulants at Hospital Admission and Discharge in the Elderly: A Prospective Observational Multicenter Study

INTRODUCTION

Direct oral anticoagulants (DOACs) were developed to overcome some of the limitations associated with vitamin K antagonists (VKAs), such as interindividual variability or the need for therapeutic drug monitoring. However, the complexity of DOAC dose regimens can still lead to dosing errors and potential bleeding-related or thromboembolic adverse events, especially in the elderly.

OBJECTIVE

Our objective was to evaluate the rate of inappropriate preadmission DOAC prescriptions at hospital and to evaluate the ability of hospitals to correct them.

METHODS

An observational prospective study was conducted in elderly patients (aged ≥ 65 years) hospitalized in six acute units of three Parisian university hospitals between February and July 2018. DOAC prescriptions prior to admission and at discharge were analyzed according to the guidelines in the summaries of product characteristics.

RESULTS

A total of 157 patients were included in the study, with a median age of 84 years (interquartile range [IQR] 77-89). The median glomerular filtration rate, determined with the Cockcroft-Gault equation, was 48 mL/min (IQR 35-61). Apixaban was the most frequently prescribed drug, mainly for atrial fibrillation. Overall, 48 (30.6%) and 34 (22.4%) prescriptions were inappropriate prior to admission and at discharge, respectively, showing a significant decrease (p < 0.001). Hospitals significantly corrected more inappropriate prescriptions (37.5%) than they generated (4.6%) (p < 0.05). The nature of the inappropriate prescribing was underdosing (68.8% and 76.5% prior to admission and at discharge, respectively), followed by overdosing (stable rate at almost 20%) and indication errors. No risk factors for inappropriate use were identified by our analysis.

CONCLUSION

One-third of DOAC preadmission prescriptions for elderly patients were inappropriate, indicating that a need remains to strengthen DOAC prescribing guidelines in ambulatory clinical practice. However, the rate of inappropriate prescriptions decreased at patient discharge. Future studies are needed to test actions to promote the proper use of DOACs.

The Association Between Polypharmacy and Physical Function in Older Adults: a Systematic Review

BACKGROUND

Reduced physical function and polypharmacy (PPha) are two highly prevalent negative effects of aging, which are expected to increase more, since demographic aging is expected to grow rapidly within the next decades. Previous research suggests that polypharmacy (PPha) is a predictor of poor physical function and vice versa in older adults and therefore we conducted a systematic review of the literature to summarize and critically analyze the relationship between physical function and PPha and vice versa in older adults, in order to provide recent scientific evidence.

METHODS

We searched MEDLINE and Embase from their inception to 19th October 2018 for English-language observational studies or trials assessing the effect of PPha on physical function and vice versa in older adults. Two investigators independently extracted study data and assessed the quality of the studies, after having screened the available studies from the literature search. Any disagreement was resolved by consensus.

RESULTS

Eighteen observational studies met the inclusion criteria. Eight studies assessed the impact of physical function on PPha and ten studies assessed the impact of PPha on physical function. Regarding the studies with PPha measurements as the outcome, all of them, except for one, found that better physical function is associated with lower risk of PPha. Likewise, all the studies with physical function measurements as the outcome, except for one, suggested that PPha is associated with lower physical function.

DISCUSSION

Evidence examining the effect of PPha on physical function and vice versa in older adults suggests a strong bidirectional association between these two factors and clinicians should be aware of this strong relationship. The limitations of our study include the high variability in PPha definitions and physical function measures, and the treatment of PPha and physical function as constant instead of time-varying variables in the studies' analyses.

Evaluation of pharmacist interventions and commonly used medications in the geriatric ward of a teaching hospital in Turkey: a retrospective study

Purpose

Aging increases the prevalence of diseases. The elderly population is consequently often exposed to complex medication regimens. Increased drug use is one of the main reasons for drug-related problems (DRPs). The primary objective of this study was to define and classify DRPs, pharmacist interventions, and frequently prescribed medications in relation to possible DRPs in patients admitted to the geriatric ward of a teaching hospital in Turkey.

Patients and methods

Pharmacist medication review reports for 200 orders of 91 patients (mean age: 80.33±0.46) were analyzed retrospectively.

Results

A total of 1,632 medications were assessed and 329 interventions were proposed for possible DRPs in 156 orders. A total of 87.5% of the patients used five or more drugs (mean: 8.17±0.23). The number of DRPs per order was higher when polypharmacy was present (1.04±0.15 vs 1.66±0.11, P<0.05). In 71.31% of the cases, adverse drug events were recognized as the problem. The principal cause of possible DRPs was determined as drug interactions (40.12%). Only 22 potentially inappropriate medications were prescribed. The most common interventions included monitoring drug therapy (31.0%), stopping the drug (20.06%), and changing dosage (13.98%). The acceptance rate of pharmacist interventions by treating geriatrician was 85.41%. The most frequently prescribed drugs were for the nervous system, alimentary tract and metabolism, and cardiovascular system (n=358, 314, and 304, respectively). The pharmaceutical forms of 23 drugs were deemed inappropriate by pharmacists.

Conclusion

Clinical pharmacy services are still not properly implemented in Turkey. The study highlights ways in which clinical pharmacy services can be instrumental in a geriatric ward. The high acceptance rates of pharmacist recommendations concerning a wide variety of DRPs and different classes of drugs indicate that advanced collaboration among geriatricians and pharmacists is possible in interdisciplinary geriatric assessment teams in Turkey.

Discontinuation of medications at the end of life: A population study in Belgium, based on linked administrative databases

AIMS

The aim of this study was to examine the use of potentially inappropriate medication (PIM) in relation to time before death, to explore whether PIMs are discontinued at the end of life, and the factors associated with this discontinuation.

METHODS

We conducted a retrospective register-based mortality cohort study of all deceased in 2012 in Belgium, aged at least 75 years at time of death (n = 74 368), using linked administrative databases. We used STOPPFrail to identify PIMs received during the period from 12 to 6 months before death (P1) and the last 4 months (P2) of life.

RESULTS

Median age was 86 (IQR 81-90) at time of death, 57% were female, 38% were living in a nursing home, and 16% were admitted to hospital between 2 years and 4 months before death. Overall, PIM use was high, and increased towards death for all PIMs. At least one PIM was discontinued during P2 for one in five (20%) of the population, and 49% had no discontinuation. Being hospitalized in the period before the last 4 months of life, living in a nursing home, female gender and a higher number of medications used during P1 were associated with discontinuation of PIMs (respective aOR [95% CI]: 2.89 [2.73-3.06], 1.29 [1.23-1.36], 1.26 [1.20-1.32], 1.17 [1.16-1.17]).

CONCLUSION

Initial PIM use was high and increased towards death. Discontinuation was observed in only one in five PIM users. More guidance for discontinuation of PIMs is needed: practical, evidence-based deprescribing guidelines and implementation plans, training for prescribers and a better consensus on what inappropriate medication is.