[Adverse drug reaction in the elderly]

[Evaluation of oral medications in the geriatric medical care ward based on the Guidelines for Appropriate Use of Medications for the Elderly (2018), and an analysis of the number of oral medicines in relation to the nutritional route and activities of daily living (ADL) categories]

AIM

This study aimed to evaluate the use of potentially inappropriate medications (PIMs) and to examine the number of oral medicines based on the swallowing function and activities of daily living (ADL) categories in a geriatric medical care ward.

METHODS

A prospective investigation of oral medication use of 124 consecutive patients (male, n=58; female, n=66) admitted to a geriatric medical care ward was conducted from November 2019 to October 2020. Nutritional routes and ADL categories were quantitatively assessed, and the respective medication quantities were subjected to a statistical analysis.

RESULTS

The average number of oral medications was 5.8 at acute care admission, 4.4 upon transfer to the geriatric medical care ward and 4.8 at discharge. Approximately 30% of oral medications were classified as PIMs, including antithrombotic agents, diuretics, antidiabetic drugs, magnesium oxide, sleep and anxiolytic medications, and antipsychotic drugs. Magnesium oxide, antipsychotic drugs, sleep and anxiolytic medications were frequently discontinued during the patient's stay at the geriatric medical care ward. The proportion of PIMs significantly decreased from 35.1% at admission, to 28.8% at ward transfer, and 24.3% at discharge (P<0.01). The number of oral medicines at discharge varied based on the nutritional route, with averages of 5.5 for oral intake, 3.6 for enteral nutrition, and 0.7 for venous nutrition. It also varied based on ADL categories, with averages of 6.0 for ADL 1, 5.8 for ADL 2, and 3.8 for ADL 3.

CONCLUSION

The use of PIMs decreased in the geriatric medical care ward. A reduced swallowing function and lower ADL were associated with a decrease in the quantity of oral medicines.

Effect of number of medications and complexity of regimens on medication adherence and blood pressure management in hospitalized patients with hypertension

INTRODUCTION

Good adherence of antihypertensives is recommended for the accomplishment of hypertension therapy. The number of medications and characteristics contributing to medication regimen complexity, such as dosage forms and dosing frequency, are known to influence medication adherence. However, the effect of medication regimen complexity on the therapeutic efficacy of medicines remains to be clarified. In the present study, we retrospectively investigated the effect of number of medications and medication regimen complexity on medication adherence and therapeutic efficacy in patients with hypertension.

METHODS

According to the inclusion and exclusion criteria, 1,057 patients, who were on medications including antihypertensives on admission at the Mie University Hospital between July 2018 and December 2018, were enrolled in this study. Poor blood pressure management was defined if the systolic or diastolic blood pressure were ≥140 mmHg or ≥ 90 mmHg. Medication regimen complexity was quantified using the medication regimen complexity index (MRCI) score.

RESULTS

Among 1,057 patients, 164 and 893 patients were categorized into poor and good adherence groups, respectively. The multivariate analyses revealed that age ≥ 71 years and oral MRCI score ≥ 19.5 but not number of oral medications were extracted as risk factors for poor medication adherence. Medication adherence and blood pressure management were poor in the group with oral MRCI score ≥ 19.5, regardless of the age. The rate of readmission was similar.

CONCLUSION

Our study is the first to demonstrate that medication regimen complexity rather than number of medications is closely related to medication adherence and blood pressure management. Hence, physicians and/or pharmacists should consider the complexity of medication regimens while modifying them.

Prescription of potentially inappropriate medications in elderly outpatients: a survey using 2015 Japanese Guidelines

Background In recent years, rapid increase of elderly population has become a major social problem in developed countries. They tend to receive an increasing number of prescibed drugs due to multiple illnesses, which might include inappropriate medications, in turn leading to health hazards and rising healthcare cost. Objective To evaluate the current status of potentially inappropriate medications prescribed for elderly outpatients and filled by dispensing pharmacies using the recent Japanese Guidelines, and to determine factors that are related to prescribing potentially inappropriate medications. Setting A cross-sectional study of older patients (≥ 75 years) who visited dispensing pharmacies in the Ibaraki Prefecture, Japan. Method We identified patients prescribed potentially inappropriate medications using the "List of Medications that Require Particularly Careful Administration" in the Guidelines (Guideline List). We explored patient's factors related to polypharmacy (≥ 5 medications) and prescription of inappropriate medications through multivariate analysis, and a cutoff value for predicting potentially inappropriate medications through receiver operating characteristic curve analysis. Main outcome measure Prevalence of polypharmacy and potentially inappropriate medications, and patient's factors associated with them. Results Of 8080 patients (39,252 medications) who visited pharmacies during the study period, 43.1% (3481) were prescribed ≥ 5 medications. In total, 2157 patients (26.7%) were prescribed at least one potentially inappropriate medication. The most prescribed inappropriate medication class was (benzodiazepine) sedatives and hypnotics. Potentially inappropriate medications were 7.11 times (95% CI 6.29-8.03) and 1.51 times (1.34-1.71) more likely to be prescribed for patients with ≥ 5 medications and those prescribed by multiple physicians, respectively. A cutoff value for potentially inappropriate medications was found to be five for the total number of medications and four for the number of chronic medications with a systemic effect. Conclusion Prescription of potentially inappropriate medications was increased among patients with ≥ 5 medications and those chronically prescribed ≥ 4 medications with a systemic effect. The Guideline List should be actively used to screen such patients, and to carefully examine prescriptions. Particular care should be exercised when patients are visiting multiple physicians.

Influence of polypharmacy on heart rate variability in older adults at the Hiroshima Atomic Bomb Survivors Recuperation Research Center, Japan

BACKGROUND

Many studies have identified the risk of polypharmacy, but physiological evidence and methods of evaluation in these studies were poor. The relationship between polypharmacy and heart rate variability in older adults remains unclear. We investigated the relationship between polypharmacy in older adults, including atomic bomb survivors, and heart rate variability.

METHODS

We surveyed 56 older adults who did not need nursing care assistance in the Hiroshima Atomic Bomb Survivors Recuperation Center. Chronic diseases, types of medication, and lifestyle were assessed, and heart rate variability at rest was measured. We calculated heart rate variability indices including standard deviation of normal-to-normal RR intervals (SDNN), total power (TP), and very low frequency (VLF) and analyzed the relationship between the number of daily medication types and heart rate variability indices in older adults. The differences in heart rate variability indices were analyzed using six medications as a cut-off point.

RESULTS

Participants included 36 atomic bomb survivors and 20 non-atomic bomb survivors. The mean number of medication types was 3.6±3.4 (mean±standard deviation). SDNN, TP, and VLF decreased with an increased number of medications in all participants (P<0.01). When the standard of polypharmacy was set to more than six types of medications, SDNN, TP, and VLF were significantly lower in older adults who took six or more medications. Additionally, the mean number of medication types among atomic bomb survivors was higher than that of non-atomic bomb survivors (P = 0.008). The SDNN was significantly lower when atomic bomb survivors took six or more medications (P<0.001).

CONCLUSIONS

We found that a lower heart rate variability in older adults, including atomic bomb survivors, is associated with polypharmacy. We showed physiological evidence of the influence of polypharmacy, which may be important for the healthy life expectancy and prognosis in older adults.

Impact of Polypharmacy on the Rehabilitation Outcome of Japanese Stroke Patients in the Convalescent Rehabilitation Ward

Background. A risk factor associated with stroke onset is chronic kidney disease (CKD). To prevent stroke reoccurrence, it is necessary to strictly manage blood pressure, lipids, and plasma glucose. Therefore, some cases are forced to polypharmacy, elderly patients in particular. Polypharmacy often leads to adverse drug reactions and has the potential to negatively affect the rehabilitation of stroke patients. The aim of the present study was to investigate the effects of polypharmacy using a functional independence measure (FIM). Methods. A total of 144 stroke patients with CKD were included in the present analysis. We divided stroke patients into those taking six or more drugs (polypharmacy group) and those taking less than six drugs (nonpolypharmacy group) upon admission. Patient background features, laboratory data, and FIM scores were compared. Results. FIM-Motor (FIM-M) efficiency, age, and diabetes mellitus were positively associated with polypharmacy. FIM-M efficiency in the polypharmacy group was significantly lower than in the nonpolypharmacy group. Conclusion. Polypharmacy interferes with the effect of rehabilitation in stroke patients with CKD. Pharmacists and doctors should make efforts to optimize medications to be able to respond to the outcome of each patient.

[Medication reduction in a convalescent rehabilitation ward]

BACKGROUND

Senior citizens who have multiple diseases often receive multiple medications (polypharmacy). Because of the increased risk of adverse drug reactions with polypharmacy, trying to minimize the number of medications is important to medical care. Some rehabilitation physicians often treat multiple diseases alone, and hospitalization for rehabilitation provides a good opportunity to improve prescription practices. Our rehabilitation department has implemented a program to minimize the quantity of medications prescribed to hospitalized patients.

AIM

To examine reductions in medication consumption through suitable prescribing patterns during rehabilitation.

METHODS

We investigated prescription practices and the reduction of medications from the clinical records of 203 patients who were admitted to our rehabilitation department from January to December, 2009.

RESULTS

Of the 203 patients, 131 (64.5%) were 75 years old or more, and 77 (37.9%) patients were less than 45 kg in weight. Patients took an average of 6.49 medications on admission and 6.02 on discharge. Ninety-two (45.3%) patients experienced a reduction in medication within one month. After a month, 77 (37.9%) patients experienced an increase in medication and only seven (3.4%) a decrease. No patient whose medications were reduced experienced adverse drug withdrawal reactions. The 14 patients whose antihypertensive medication was reduced experienced an excellent course. Similarly, those whose narcoleptic medications were reduced also did well.

CONCLUSIONS

Medications should be optimized, and reduced if possible, in the early stages of hospitalization. In the absence of adverse events, it appears possible to decrease the quantity of analgesic and gastrointestinal drugs by one-third.

[Creatinine clearance estimation in the extremely elderly subjects]

BACKGROUND

It has been reported that elderly outpatients take at least 6 different kinds of medication.

PURPOSE

To know which formula will best predict creatinine clearance, because 24-hour urine collection is difficult for elderly outpatients.

PATIENTS AND METHODS

We compared four types of formulae (Cockcroft and Gault, Yasuda, Orita, Walser) to estimate creatinine clearance using serum creatinine of 143 elderly inpatients (73 men, 70 women, mean age 82.9 +/- 8.6 years old) including 67 extremely elderly people with various underlying diseases.

RESULT

The formula of Cockcroft and Gault showed the best correlation with creatinine clearance in the extremely elderly subjects (r = 0.74) as well as in people under 85 years (r = 0.76). However, the estimated values of the extremely elderly women were lower than actual creatinine clearance.

CONCLUSION

The formula of Cockcroft and Gault is the best predictive equation of creatinine clearance, except in the extremely elderly women.