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Olender RT, Roy S, Jamieson HA, Hilmer SN, Nishtala PS. Drug Burden Index is a Modifiable Predictor of 30-Day-Hospitalization in Community-Dwelling Older Adults with Complex Care Needs: Machine Learning Analysis of InterRAI Data. J Gerontol A Biol Sci Med Sci 2024:glae130. [PMID: 38733108 DOI: 10.1093/gerona/glae130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Older adults (≥ 65 years) account for a disproportionately high proportion of hospitalization and in-hospital mortality, some of which may be avoidable. Although machine learning (ML) models have already been built and validated for predicting hospitalization and mortality, there remains a significant need to optimise ML models further. Accurately predicting hospitalization may tremendously impact the clinical care of older adults as preventative measures can be implemented to improve clinical outcomes for the patient. METHODS In this retrospective cohort study, a dataset of 14,198 community-dwelling older adults (≥ 65 years) with complex care needs from the Inter-Resident Assessment Instrument database was used to develop and optimise three ML models to predict 30-day-hospitalization. The models developed and optimized were Random Forest (RF), XGBoost (XGB), and Logistic Regression (LR). Variable importance plots were generated for all three models to identify key predictors of 30-day-hospitalization. RESULTS The area under the receiver operating characteristics curve for the RF, XGB and LR models were 0.97, 0.90 and 0.72, respectively. Variable importance plots identified the Drug Burden Index and alcohol consumption as important, immediately potentially modifiable variables in predicting 30-day-hospitalization. CONCLUSIONS Identifying immediately potentially modifiable risk factors such as the Drug Burden Index and alcohol consumption is of high clinical relevance. If clinicians can influence these variables, they could proactively lower the risk of 30-day-hospitalization. ML holds promise to improve the clinical care of older adults. It is crucial that these models undergo extensive validation through large-scale clinical studies before being utilized in the clinical setting.
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Affiliation(s)
| | - Sandipan Roy
- Department of Mathematical Sciences, University of Bath, UK
| | - Hamish A Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Sarah N Hilmer
- Kolling Institute, Faculty of Medicine and Health, Northern Clinical School, The University of Sydney and Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Prasad S Nishtala
- Department of Life Sciences & Centre for Therapeutic Innovation, University of Bath, UK
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Tanana L, Latif A, Nishtala PS, Chen TF. Investigating Variations in Medicine Approvals for Attention-Deficit/Hyperactivity Disorder: A Cross-Country Document Analysis Comparing Drug Labeling. J Atten Disord 2024:10870547231224088. [PMID: 38327043 DOI: 10.1177/10870547231224088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
OBJECTIVE This study aimed to compare the approval of medicines for attention deficit/hyperactivity disorder (ADHD) for pediatric patients across five countries. METHOD A document analysis was completed, using the drug labeling for ADHD medicines from five countries; United Kingdom, Australia, New Zealand, Canada and United States (US). Comparisons of available formulations and approval information for ADHD medicine use in pediatric patients were made. RESULTS The US had the highest number of approved medicines and medicine forms across the studied countries (29 medicine forms for 10 approved medicines). Approved age and dosage variations across countries and missing dosage information were identified in several drug labeling. CONCLUSIONS The discrepancies in approval information in ADHD medicine drug labeling and differing availability of medicine formulations across countries suggest variations in the management of ADHD across countries. The update of drug labeling and further research into reasons for variability and impact on practice are needed.
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Affiliation(s)
- Laila Tanana
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Asam Latif
- University of Nottingham, Nottingham, UK
| | | | - Timothy F Chen
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Chinzowu T, Chyou TY, Nishtala PS. Antibiotic-Associated Acute Kidney Injury Among Older Adults: A Case-Crossover Study. Clin Drug Investig 2024; 44:131-139. [PMID: 38170348 DOI: 10.1007/s40261-023-01339-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND AND OBJECTIVES Drug-related acute kidney injury is quite common in older adults. The associated drugs, including antibiotics, are often co-prescribed. The objective of this study was to ascertain antibiotic-associated acute kidney injury (AKI) in older adults aged 65 years or above in New Zealand using a case-crossover study design. METHODS The International Statistical Classification of Diseases and Related Health Problems, tenth revision, Australian modification code N17.x was used to identify all individuals aged 65 years and above with a diagnosis of incident AKI on admission between 1 January 2005 and 31 December 2020, from the New Zealand National Minimum Data Set. A case-crossover cohort for antibiotic exposures, with a 3 day case period and two 30 day washout periods, summed up to a 66 day study period, was created. Using conditional logistic regression, the changed odds of AKI due to exposure to an antibiotic was calculated as matched odds ratios and their 95% confidence intervals. RESULTS A total of 2399 incident cases of AKI were identified between 2005 and 2020 among older adults. The adjusted odds of consuming sulfamethoxazole/trimethoprim antibiotic during the case period was 3.57 times (95% CI 2.86-4.46) higher than the reference period among the incident AKI cases. Fluoroquinolone utilization was also associated with incident AKI (adjusted OR = 2.56; 95% CI 1.90-3.46). CONCLUSION The potential of sulfamethoxazole/trimethoprim and fluoroquinolones to be associated with AKI raises the significant need for vigilant prescribing of these antibiotics in older adults.
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Affiliation(s)
| | - Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Prasad S Nishtala
- Department of Life Sciences, University of Bath, Bath, BA2 7AY, UK
- Centre for Therapeutic Innovation, University of Bath, Bath, UK
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Duncan S, Bergler HU, Menclova A, Pickering JW, Nishtala PS, Ailabouni N, Hilmer SN, Mangin D, Jamieson H. The Drug Burden Index and Level of Frailty as Determinants of Healthcare Costs in a Cohort of Older Frail Adults in New Zealand. Value Health Reg Issues 2024; 41:72-79. [PMID: 38245933 DOI: 10.1016/j.vhri.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVES Frailty is common in older people and is associated with increased use of healthcare services and ongoing use of multiple medications. This study provides insights into the healthcare cost structure of a frail group of older adults in Aotearoa, New Zealand. Furthermore, we investigated the relationship between participants' anticholinergic and sedative medication burden and their total healthcare costs to explore the viability of deprescribing interventions within this cohort. METHODS Healthcare cost analysis was conducted using data collected during a randomized controlled trial within a frail, older cohort. The collected information included participant demographics, medications used, frailty, cost of service use of aged residential care and outpatient hospital services, hospital admissions, and dispensed medications. RESULTS Data from 338 study participants recruited between 25 September 2018 and 30 October 2020 with a mean age of 80 years were analyzed. The total cost of healthcare per participant ranged from New Zealand $15 (US dollar $10) to New Zealand $270 681 (US dollar $175 943) over 6 months postrecruitment into the study. Four individuals accounted for 26% of this cohort's total healthcare cost. We found frailty to be associated with increased healthcare costs, whereas the drug burden was only associated with increased pharmaceutical costs, not overall healthcare costs. CONCLUSIONS With no relationship found between a patient's anticholinergic and sedative medication burden and their total healthcare costs, more research is required to understand how and where to unlock healthcare cost savings within frail, older populations.
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Affiliation(s)
- Shnece Duncan
- Department of Economics and Finance, University of Canterbury, Christchurch, New Zealand.
| | - Hans Ulrich Bergler
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Andrea Menclova
- Department of Economics and Finance, University of Canterbury, Christchurch, New Zealand
| | - John W Pickering
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Prasad S Nishtala
- Department of Life Sciences, Centre for Therapeutic Innovation, University of Bath, Bath, England, UK
| | - Nagham Ailabouni
- The Pharmacy Australian Centre of Excellence (PACE), School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Sarah N Hilmer
- Geriatric Pharmacology, Faculty of Medicine and Health, Northern Clinical School, Kolling Institute, University of Sydney and Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Dee Mangin
- Primary Care Research Group, University of Otago, Christchurch, New Zealand; Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Hamish Jamieson
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
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Olender RT, Roy S, Nishtala PS. Application of machine learning approaches in predicting clinical outcomes in older adults - a systematic review and meta-analysis. BMC Geriatr 2023; 23:561. [PMID: 37710210 PMCID: PMC10503191 DOI: 10.1186/s12877-023-04246-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 08/19/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Machine learning-based prediction models have the potential to have a considerable positive impact on geriatric care. DESIGN Systematic review and meta-analyses. PARTICIPANTS Older adults (≥ 65 years) in any setting. INTERVENTION Machine learning models for predicting clinical outcomes in older adults were evaluated. A random-effects meta-analysis was conducted in two grouped cohorts, where the predictive models were compared based on their performance in predicting mortality i) under and including 6 months ii) over 6 months. OUTCOME MEASURES Studies were grouped into two groups by the clinical outcome, and the models were compared based on the area under the receiver operating characteristic curve metric. RESULTS Thirty-seven studies that satisfied the systematic review criteria were appraised, and eight studies predicting a mortality outcome were included in the meta-analyses. We could only pool studies by mortality as there were inconsistent definitions and sparse data to pool studies for other clinical outcomes. The area under the receiver operating characteristic curve from the meta-analysis yielded a summary estimate of 0.80 (95% CI: 0.76 - 0.84) for mortality within 6 months and 0.81 (95% CI: 0.76 - 0.86) for mortality over 6 months, signifying good discriminatory power. CONCLUSION The meta-analysis indicates that machine learning models display good discriminatory power in predicting mortality. However, more large-scale validation studies are necessary. As electronic healthcare databases grow larger and more comprehensive, the available computational power increases and machine learning models become more sophisticated; there should be an effort to integrate these models into a larger research setting to predict various clinical outcomes.
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Affiliation(s)
- Robert T Olender
- Department of Life Sciences, University of Bath, Bath, BA2 7AY, UK.
| | - Sandipan Roy
- Department of Mathematical Sciences, University of Bath, Bath, BA2 7AY, UK
| | - Prasad S Nishtala
- Department of Life Sciences & Centre for Therapeutic Innovation, University of Bath, Bath, BA2 7AY, UK
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Hikaka J, Abey-Nesbit R, McIntosh B, Schluter PJ, Nishtala PS, Scrase R, Jamieson HA. Utility of Big Data to Explore Medication Adherence in Māori and Non-Māori Community-Dwelling Older Adults with Heart Failure in Aotearoa New Zealand: A Cross-sectional Study. Drugs Aging 2023; 40:847-855. [PMID: 37386345 PMCID: PMC10450015 DOI: 10.1007/s40266-023-01044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Medication adherence improves morbidity and mortality-related outcomes in heart failure, and knowledge of patterns of medication adherence supports patient and clinician decision-making. Routinely collected national data facilitate the exploration of medication adherence and associated factors in older adults with heart failure, including the association between ethnicity and adherence. There are known inequities in access to medicines between Māori (Indigenous People of Aotearoa New Zealand) and non-Māori, yet ethnic variation in medicines adherence in community-dwelling older adults with heart failure has not been explored. OBJECTIVE Here we identify medication adherence rates for community-dwelling older adults diagnosed with heart failure and differences in adherence rates between Māori and non-Māori. METHODS Cross-sectional analysis of interRAI (comprehensive standardised assessment) data in a continuously recruited national cohort from 2012 to 2019. RESULTS Overall, 13,743 assessments (Māori N = 1526) for older community-dwelling adults with heart failure diagnoses were included. The mean age of participants was 74.5 years [standard deviation (SD) 9.1 years] for Māori and 82.3 years (SD 7.8 years) non-Māori. In the Māori cohort, 21.8% did not adhere fully to their medication regimen, whereas in the non-Māori cohort, this figure was 12.8%. After adjusting for confounders, the Māori cohort were more likely to be medication non-adherent than non-Māori [prevalence ratio 1.53, 95% confidence interval (CI) 1.36-1.73]. CONCLUSIONS There was a significant disparity between Māori and non-Māori concerning medication adherence. Given the international use of the interRAI-HC assessment tool, these results have significant transferability to other countries and allow the identification of underserved ethnic groups for which culturally appropriate interventions can be targeted.
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Affiliation(s)
- Joanna Hikaka
- Facility of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - Brendon McIntosh
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Kia Kaha Chemists, Christchurch, New Zealand
| | - Philip J Schluter
- Te Kaupeka Oranga/Faculty of Health, Te Whare Wānanga o Waitaha/University of Christchurch, Christchurch, 8041, New Zealand
- Primary Care Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, Australia
| | - Prasad S Nishtala
- Department of Life Sciences, Centre for Therapeutic Innovation, University of Bath, Bath, United Kingdom
| | - Richard Scrase
- Department of Medicine, University of Otago, Burwood Campus, PO box, 4345, Christchurch, New Zealand
| | - Hamish A Jamieson
- Department of Medicine, University of Otago, Burwood Campus, PO box, 4345, Christchurch, New Zealand.
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Nishtala PS, Pickering JW, Bergler U, Mangin D, Hilmer SN, Jamieson H. Post Hoc Analyses of a Randomized Controlled Trial for the Effect of Pharmacist Deprescribing Intervention on the Anticholinergic Burden in Frail Community-Dwelling Older Adults. J Am Med Dir Assoc 2023:S1525-8610(23)00478-4. [PMID: 37339754 DOI: 10.1016/j.jamda.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVES Anticholinergic burden is detrimental to cognitive health. Multiple studies found that a high anticholinergic burden is associated with an increased risk for dementia, changes to the brain structure, function, and cognitive decline. We performed a post hoc analysis of a randomized controlled deprescribing trial. We compared the effect of the intervention on baseline anticholinergic burden across the treatment and control groups and the time of recruitment before and after a lockdown due to the COVID pandemic with subgroup analyses by baseline frailty index. DESIGN Randomized controlled trial. SETTINGS AND PARTICIPANTS We analyzed data from a de-prescribing trial of older adults (>65 years) previously conducted in New Zealand that was focused on reducing the Drug Burden Index (DBI). METHODS We used the anticholinergic cognitive burden (ACB) to quantify the impact of the intervention on reducing the anticholinergic burden. Participants not taking anticholinergics at the start of the trial were excluded. The primary outcome for this subgroup analysis was a change in ACB, measured with the ĝHedges statistic describing the difference in standard deviation units of this change between intervention and control. For this analysis, the trial participants were stratified into low, medium, and high frailty and timing into prior- and post-lockdown (public health measures for COVID-19). RESULTS Among the 295 participants in this analysis, the median (IQR) age was 79 (74, 85), and 67% were women. For the primary outcome ĝHedges = -0.04 (95% CI -0.26 to 0.19) with a -0.23 mean reduction in ACB in the intervention arm and -0.19 in the control arm. Before lockdown ĝHedges = -0.38 (95% CI -0.84 to 0.04) and post-lockdown ĝHedges = 0.07 (95% CI -0.19 to 0.33). The mean change in ACB for each of the frailty strata was as follows: low frailty (-0.02; 95% CI -0.65 to 0.18); medium frailty (0.05; 95% CI -0.28 to 0.38); high frailty (0.08; 95% CI -0.40 to 0.56). CONCLUSIONS AND IMPLICATIONS The study did not provide evidence for the effect of pharmacist deprescribing intervention on reducing the anticholinergic burden. However, this post hoc analysis examined the impact of COVID on the effectiveness of the intervention, and further research in this area may be warranted.
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Affiliation(s)
- Prasad S Nishtala
- Centre for Therapeutic Innovation, Department of Pharmacy and Pharmacology, University of Bath, United Kingdom.
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Ulrich Bergler
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Dee Mangin
- University of Otago, Christchurch, New Zealand; McMaster University, Hamilton, Ontario, Canada
| | - Sarah N Hilmer
- Faculty of Medicine and Health, Northern Clinical School, Kolling Institute, University of Sydney and Royal North Shore Hospital, St Leonards, Australia
| | - Hamish Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand; Burwood Hospital, Christchurch, New Zealand
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Shabu A, Nishtala PS. Safety outcomes associated with the Moderna COVID-19 vaccine (mRNA-1273): a literature review. Expert Rev Vaccines 2023; 22:393-409. [PMID: 37133747 DOI: 10.1080/14760584.2023.2209177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Current safety data from Phase 3 clinical trials have concluded that apart from transient local and systemic reactions, no safety concerns were identified for the Moderna COVID-19 vaccine (mRNA-1273). However, Phase 3 studies are insufficient to detect rare adverse events (AEs), including anaphylactic reactions or myocarditis. A literature search of the two major electronic databases, Embase and Pubmed, was performed to enable the identification and characterization of all relevant articles from December 2020 to November 2022. AREAS COVERED This narrative review aims to summarize the key safety outcomes associated with the mRNA-1273 vaccine to inform healthcare decisions and increase public awareness of mRNA-1273 vaccine safety. The primary adverse events (AEs) reported within a diverse population, including children, adolescents, older adults, pregnant women, and cancer patients receiving the mRNA-1273 vaccine, were; localized injection site pain, fatigue, headache, myalgia, and chills. In addition, the mRNA-1273 vaccine was also associated with; less than a 1-day change in the menstrual cycle, a 10-fold higher risk of myocarditis and pericarditis within young males aged 18-29 years and increased levels of anti-polyethylene glycol (PEG) antibodies. EXPERT OPINION The transient nature of commonly observed AEs and the rare occurrence of severe events within mRNA-1273 recipients show no significant safety concerns which should prevent vaccination. However, large-scale epidemiological studies with longer follow-up periods are required to surveillance rare safety outcomes associated with this vaccine.
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Affiliation(s)
- Angel Shabu
- Department of Life Sciences, University of Bath, Bath, BA2 7AY, United Kingdom
| | - Prasad S Nishtala
- Department of Life Sciences, University of Bath, Bath, BA2 7AY, United Kingdom
- Centre for Therapeutic Innovation, University of Bath, Bath BA2 7AY, United Kingdom
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Phutietsile GO, Fotaki N, Jamieson HA, Nishtala PS. The association between anticholinergic burden and mobility: a systematic review and meta-analyses. BMC Geriatr 2023; 23:161. [PMID: 36949391 PMCID: PMC10035151 DOI: 10.1186/s12877-023-03820-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 02/13/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND As people age, they accumulate several health conditions, requiring the use of multiple medications (polypharmacy) to treat them. One of the challenges with polypharmacy is the associated increase in anticholinergic exposure to older adults. In addition, several studies suggest an association between anticholinergic burden and declining physical function in older adults. OBJECTIVE/PURPOSE This systematic review aimed to synthesise data from published studies regarding the association between anticholinergic burden and mobility. The studies were critically appraised for the strength of their evidence. METHODS A systematic literature search was conducted across five electronic databases, EMBASE, CINAHL, PSYCHINFO, Cochrane CENTRAL and MEDLINE, from inception to December 2021, to identify studies on the association of anticholinergic burden with mobility. The search was performed following a strategy that converted concepts in the PECO elements into search terms, focusing on terms most likely to be found in the title and abstracts of the studies. For observational studies, the risk of bias was assessed using the Newcastle Ottawa Scale, and the Cochrane risk of bias tool was used for randomised trials. The GRADE criteria was used to rate confidence in evidence and conclusions. For the meta-analyses, we explored the heterogeneity using the Q test and I2 test and the publication bias using the funnel plot and Egger's regression test. The meta-analyses were performed using Jeffreys's Amazing Statistics Program (JASP). RESULTS Sixteen studies satisfied the inclusion criteria from an initial 496 studies. Fifteen studies identified a significant negative association of anticholinergic burden with mobility measures. One study did not find an association between anticholinergic intervention and mobility measures. Five studies included in the meta-analyses showed that anticholinergic burden significantly decreased walking speed (0.079 m/s ± 0.035 MD ± SE,95% CI: 0.010 to 0.149, p = 0.026), whilst a meta-analysis of four studies showed that anticholinergic burden significantly decreased physical function as measured by three variations of the Instrumental Activities of Daily Living (IADL) instrument 0.27 ± 0.12 (SMD ± SE,95% CI: 0.03 to 0.52), p = 0.027. The results of both meta-analyses had an I2 statistic of 99% for study heterogeneity. Egger's test did not reveal publication bias. CONCLUSION There is consensus in published literature suggesting a clear association between anticholinergic burden and mobility. Consideration of cognitive anticholinergic effects may be important in interpreting results regarding the association of anticholinergic burden and mobility as anticholinergic drugs may affect mobility through cognitive effects.
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Affiliation(s)
| | - Nikoletta Fotaki
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, UK
- Centre for Therapeutic Innovation, University of Bath, Bath, BA2 7AY, UK
| | - Hamish A Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, UK
- Centre for Therapeutic Innovation, University of Bath, Bath, BA2 7AY, UK
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Nicholls C, Chyou TY, Nishtala PS. Analysis of the nervous system and gastrointestinal adverse events associated with solifenacin in older adults using the US FDA adverse event reporting system. Int J Risk Saf Med 2023; 34:63-73. [PMID: 35491805 DOI: 10.3233/jrs-210054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Antimuscarinics are the backbone of the pharmacological management of overactive bladder. Still, concerns have been raised over the nervous system (NS) adverse drug events (AEs) due to their dissimilarities to muscarinic receptor-subtype affinities. OBJECTIVE This study aimed to identify the nervous system and gastrointestinal adverse drug events (ADEs) associated with solifenacin use in older adults (≥65 years). METHODS A case/non-case analysis was performed on the reports submitted to the FDA Adverse Event Reporting System (FAERS) between 01/01/2004 and 30/06/2020. Cases were reports for solifenacin with ≥1 ADEs as preferred terms included in the Medical Dictionary of Regulatory Activities (MedDRA) system organ classes 'nervous system' or 'gastrointestinal' disorders. Non-cases were all other remaining reports for solifenacin. The case/non-cases was compared between solifenacin and other bladder antimuscarinics. Frequentist approaches, including the proportional reporting ratio (PRR) and reporting odds ratio (ROR), were used to measure disproportionality. The empirical Bayesian Geometric Mean (EBGM) score and information component (IC) value were calculated using a Bayesian approach. A signal was defined as the lower limit of 95% confidence intervals of ROR ≥ 2, PRR ≥ 2, IC > 0, EBGM > 1, for ADEs with ≥4 reports. RESULTS 107 MedDRA preferred terms (PTs) comprising 970 ADE reports were retrieved for nervous system disorders associated with solifenacin. For gastrointestinal disorders, 129 MedDRA PTs comprising 1817 ADE reports were retrieved. Statistically significant results were found for 'altered state of consciousness': ROR = 9.71 (2.13-44.35), PRR = 9.69 (2.12-44.2) and IC = 1.29 (0.93-1.66). CONCLUSIONS The disproportionality reporting of 'altered state of consciousness', a previously unidentified ADE, was unexpected. Further monitoring of this ADE is needed to ensure patient safety, as this could be linked to poor balance and falls in older adults.
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Affiliation(s)
- Connie Nicholls
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, Otago, New Zealand
| | - Prasad S Nishtala
- Pharmacy and Pharmacology, Centre for Therapeutic Innovation, University of Bath, Bath, UK
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Shabu A, Nishtala PS. Analysis of the adverse events following the mRNA-1273 COVID-19 vaccine. Expert Rev Vaccines 2023; 22:801-812. [PMID: 37723099 DOI: 10.1080/14760584.2023.2260477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/14/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE This study aims to characterize the adverse events (AEs) following the administration of the mRNA-1273 COVID-19 vaccine from the Vaccine Adverse Event Reporting System (VAERS) data. METHODS In this case/non-case analysis, reports between 1 January 2021, and 27 October 2022, were extracted from VAERS. AEs were defined as preferred terms (PTs) by Medical Dictionary for Regulatory Activities (MedDRA) terminology. Disproportionality analyses were conducted to calculate the reporting odds and proportional reporting ratios. The Bayesian approach was used to calculate information component (IC) values and Empirical Bayesian Geometric Mean scores for all the AEs detected. RESULTS 186 MedDRA PTs compromising 702,495 AEs associated with the mRNA-1273 vaccine were identified. Three statistically significant signals were identified for general and systemic AEs, administration site conditions, and product issues. Cardiac disorders were rarely reported, the most common being; 489 reports for 'myocarditis' (19.44%), 475 for 'acute myocardial infarction' (18.88%), 457 for 'myocardial infarction' (18.16%), 290 for 'bradycardia' (11.53%) and 281 for 'pericarditis' (11.17%). CONCLUSIONS The most frequently identified AEs following mRNA-1273 vaccination agree with those listed within the Summary of Product Characteristics. In addition, disproportionality analysis did not find any statistically significant signals for myocarditis or pericarditis.
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Affiliation(s)
- Angel Shabu
- Department of Life Sciences, University of Bath, Bath, UK
| | - Prasad S Nishtala
- Department of Life Sciences, University of Bath, Bath, UK
- Centre for Therapeutic Innovation, University of Bath, Bath, UK
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Orogun L, Chyou TY, Nishtala PS. Acute renal failure and cardiac arrhythmias associated with remdesivir use in patients with COVID-19 infections: Analysis using the US FDA adverse event reporting system. Int J Risk Saf Med 2023; 34:87-99. [PMID: 37154187 DOI: 10.3233/jrs-220009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Recently, antivirals, including remdesivir, have been repurposed to treat COVID-19 infections. Initial concerns have been raised about the adverse renal and cardiac events associated with remdesivir. OBJECTIVE This study aimed to analyse the adverse renal and cardiac events associated with remdesivir in patients with COVID-19 infections using the US FDA adverse event reporting system. METHOD A case/non-case method was used to determine adverse drug events associated with remdesivir as the primary suspect drug between January 1, 2020, and November 11, 2021, for patients with COVID-19 infections. Cases were reports for remdesivir with ≥1 ADEs as preferred terms included in the Medical Dictionary of Regulatory Activities (MedDRA) system organ classes 'Renal and urinary disorders' or 'cardiac' disorders. To measure disproportionality in reporting of ADEs, frequentist approaches, including the proportional reporting ratio (PRR) and reporting odds ratio (ROR), were used. The empirical Bayesian Geometric Mean (EBGM) score and information component (IC) value were calculated using a Bayesian approach. A signal was defined as the lower limit of 95% confidence intervals of ROR ≥ 2, PRR ≥ 2, IC > 0, and EBGM > 1 for ADEs with ≥4 reports. Sensitivity analyses were undertaken by excluding reports for non-Covid indications and medications strongly associated with AKI and cardiac arrhythmias. RESULTS In the main analysis for remdesivir use in patients with COVID-19 infections, we identified 315 adverse cardiac events comprising 31 different MeDRA PTs and 844 adverse renal events comprising 13 different MeDRA PTs. Regarding adverse renal events, disproportionality signals were noted for "renal failure" (ROR = 2.8 (2.03-3.86); EBGM = 1.92 (1.58-2.31), "acute kidney injury" (ROR = 16.11 (12.52-20.73); EBGM = 2.81 (2.57-3.07), "renal impairment" (ROR = 3.45 (2.68-4.45); EBGM = 2.02 (1.74-2.33). Regarding adverse cardiac events, strong disproportionality signals were noted for "electrocardiogram QT prolonged" (ROR = 6.45 (2.54-16.36); EBGM = 2.04 (1.65-2.51), "pulseless electrical activity" (ROR = 43.57 (13.64-139.20); EBGM = 2.44 (1.74-3.33), "sinus bradycardia" (ROR = 35.86 (11.16-115.26); EBGM = 2.82 (2.23-3.53), "ventricular tachycardia" (ROR = 8.73 (3.55-21.45); EBGM = 2.52 (1.89-3.31). The risk of AKI and cardiac arrythmias were confirmed by sensitivity analyses. CONCLUSION This hypothesis-generating study identified AKI and cardiac arrhythmias associated with remdesivir use in patients with COVID-19 infections. The relationship between AKI and cardiac arrhythmias should be further investigated using registries or large clinical data to assess the impact of age, genetics, comorbidity, and the severity of Covid infections as potential confounders.
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Affiliation(s)
- Lisajo Orogun
- Department of Life Sciences, University of Bath, Bath, UK
| | - Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Prasad S Nishtala
- Department of Life Sciences, Centre for Therapeutic Innovation, University of Bath, Bath, UK
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Chinzowu T, Chyou T, Nishtala PS. Antibacterial-associated acute kidney injury among older adults: A post-marketing surveillance study using the FDA adverse events reporting system. Pharmacoepidemiol Drug Saf 2022; 31:1190-1198. [PMID: 35670078 PMCID: PMC9795977 DOI: 10.1002/pds.5486] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/18/2022] [Accepted: 06/05/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE Antibacterials induce a differential risk of acute kidney injury (AKI) in older adults. This study investigated the reporting risk of AKI associated with antibacterials using the individual case safety reports (ICSRs) submitted to the Food and Drug Administration Adverse Event Reporting System (FAERS) database. METHODS A case/non-case method was used to assess AKI risk associated with antibacterials between 1 January 2000 and 30 September 2021. Cases were ICSRs for antibacterials with AKI as preferred terms included in the Medical Dictionary of Regulatory Activities (MedDRA) system organ classes 'Renal and urinary disorders' disorders. The analyses were completed on a de-duplicated data set containing only the recent version of the ICSR. Signals were defined by a lower 95% confidence interval (CI) of reporting odds ratio (ROR) ≥ 2, proportional reporting ratio (PRR) ≥ 2, information component (IC) > 0, Empirical Bayes Geometric Mean (EBGM) > 1 and reports ≥4. Sensitivity analyses were conducted a priori to assess the robustness of signals. RESULTS A total of 3 680 621 reports on ADEs were retrieved from FAERS over the study period, of which 92 194 were antibacterial reports. Gentamicin, sulfamethoxazole, trimethoprim and vancomycin consistently gave strong signals of disproportionality on all four disproportionality measures and across the different sensitivity analyses: gentamicin (ROR = 2.95[2.51-3.46]), sulfamethoxazole (ROR = 2.97[2.68-3.29]), trimethoprim (ROR = 2.81[2.29-3.46]) and vancomycin (ROR = 3.35[3.08-3.64]). CONCLUSION Signals for gentamicin, sulfamethoxazole, trimethoprim and vancomycin were confirmed by using antibacterials as a comparator, adjusting for drug-related competition bias and event-related competition bias.
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Affiliation(s)
| | - Te‐Yuan Chyou
- Department of BiochemistryUniversity of OtagoDunedinNew Zealand
| | - Prasad S. Nishtala
- Department of Pharmacy & PharmacologyUniversity of BathBath,Centre for Therapeutic InnovationUniversity of BathBathUK
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Abey-Nesbit R, Bergler U, Pickering JW, Nishtala PS, Jamieson H. Development and validation of a frailty index compatible with three interRAI assessment instruments. Age Ageing 2022; 51:6653477. [PMID: 35930721 DOI: 10.1093/ageing/afac178] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND a Frailty Index (FI) calculated by the accumulation of deficits is often used to quantify the extent of frailty in individuals in specific settings. This study aimed to derive a FI that can be applied across three standardised international Residential Assessment Instrument assessments (interRAI), used at different stages of ageing and the corresponding increase in support needs. METHODS deficit items common to the interRAI Contact Assessment (CA), Home Care (HC) or Long-Term Care Facilities assessment (LTCF) were identified and recoded to form a cumulative deficit FI. The index was validated using a large dataset of needs assessments of older people in New Zealand against mortality prediction using Kaplan Meier curves and logistic regression models. The index was further validated by comparing its performance with a previously validated index in the HC cohort. RESULTS the index comprised 15 questions across seven domains. The assessment cohort and their mean frailty (SD) were: 89,506 CA with 0.26 (0.15), 151,270 HC with 0.36 (0.15) and 83,473 LTCF with 0.41 (0.17). The index predicted 1-year mortality for each of the CA, HC and LTCF, cohorts with area under the receiver operating characteristic curves (AUCs) of 0.741 (95% confidence interval, CI: 0.718-0.762), 0.687 (95%CI: 0.684-0.690) and 0.674 (95%CI: 0.670-0.678), respectively. CONCLUSIONS the results for this multi-instrument FI are congruent with the differences in frailty expected for people in the target settings for these instruments and appropriately associated with mortality at each stage of the journey of progressive ageing.
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Affiliation(s)
| | - Ulrich Bergler
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Prasad S Nishtala
- Centre for Therapeutic Innovation, Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Hamish Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand
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15
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Nishtala PS, Chyou TY. An Updated Analysis of Psychotropic Medicine Utilisation in Older People in New Zealand from 2005 to 2019. Drugs Aging 2022; 39:657-669. [PMID: 35829958 DOI: 10.1007/s40266-022-00965-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Psychotropic medicine utilisation in older adults continues to be of interest because of overuse and concerns surrounding its safety and efficacy. OBJECTIVE This study aimed to characterise the utilisation of psychotropic medicines in older people in New Zealand. METHODS We conducted a repeated cross-sectional analysis of national dispensing data from 1 January, 2005 to 31 December, 2019. We defined utilisation using the Anatomical Therapeutic Chemical classification defined daily dose system. Utilisation was measured in terms of the defined daily dose (DDD) per 1000 older people per day (TOPD). RESULTS Overall, the utilisation of psychotropic medicines increased marginally by 0.42% between 2005 and 2019. The utilisation increased for antidepressants (72.42 to 75.21 DDD/TOPD) and antipsychotics (6.06-19.04 DDD/TOPD). In contrast, the utilisation of hypnotics and sedatives (53.74-38.90 DDD/TOPD) and anxiolytics decreased (10.20-9.87 DDD/TOPD). The utilisation of atypical antipsychotics increased (4.06-18.72 DDD/TOPD), with the highest percentage change in DDD/TOPD contributed by olanzapine (520.6 %). In comparison, utilisation of typical antipsychotics was relatively stable (2.00-2.06 DDD/TOPD). The utilisation of venlafaxine increased remarkably by 5.7 times between 2005 and 2019. The utilisation of zopiclone was far greater than that of other hypnotics in 2019. CONCLUSIONS There was only a marginal increase in psychotropic medicines utilisation from 2005 to 2019 in older adults in New Zealand. There was a five-fold increase in the utilisation of antipsychotic medicines. Continued monitoring of psychotropic medicine utilisation will be of interest to understand the utilisation of antidepressants and antipsychotic medicines during the coronavirus disease 2019 pandemic year.
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Affiliation(s)
- Prasad S Nishtala
- Department of Pharmacy and Pharmacology, University of Bath, Claverton Down, Bath, BA2 7AY, UK. .,Centre for Therapeutic Innovation, University of Bath, Bath, UK.
| | - Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, Otago, New Zealand
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16
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Nishtala PS, Chyou TY. Risk of delirium associated with antimuscarinics in older adults: a case-time-control study. Pharmacoepidemiol Drug Saf 2022; 31:883-891. [PMID: 35587029 PMCID: PMC9545361 DOI: 10.1002/pds.5480] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 03/17/2022] [Accepted: 05/13/2022] [Indexed: 11/16/2022]
Abstract
Background Older adults are at an increased risk of delirium because of age, polypharmacy, multiple comorbidities and acute illness. Antimuscarinics are the backbone of the pharmacological management of overactive bladder. However, the safety profiles of antimuscarinics vary because of their dissimilarities to muscarinic receptor‐subtype affinities and are associated with differential central anticholinergic adverse effects. Objective This study aimed to examine delirium risk in new users of oxybutynin and solifenacin in older adults (≥ 65 years). In the secondary analyses, we examined the risk of delirium by type and dose of antimuscarinic. Method We applied a case‐time‐control design to investigate delirium risk in older adults who started taking oxybutynin and solifenacin. We used a nationwide inpatient hospital data (2005–2016), National Minimum Data Set, maintained by the Ministry of Health, New Zealand (NZ), to identify older adults with a new‐onset diagnosis of delirium. Eligible patients were older adults aged 65 at entry into the cohort on 1/1/2006. We used dispensing claims data to determine antimuscarinic treatment exposure. The antimuscarinic included in the study were new users of oxybutynin and solifenacin. These two antimuscarinics are subsidised by the Pharmaceutical Management Agency and are the most frequently used antimuscarinic in NZ. A conditional logistic regression model was used to compute matched odds ratios (MORs) and 95% confidence intervals (CIs). In the case‐time‐control design, we made separate analyses to evaluate the dose–response risk of delirium. Results We identified 4818 individuals (mean age 82.14) from 2005 to 2015 with incident delirium and were exposed to at least one of the antimuscarinic of interest. The case‐time‐control matched odds ratio (MOR) for delirium with oxybutynin was (2.06, 95% confidence interval [CI] 1.07–3.96). Solifenacin was not associated with delirium (0.89 95%CI 0.64–1.23). In the sensitivity analyses, the case‐time‐control MOR for delirium using a shorter risk period (0–3 days) did not change the results. The dose–response risk of delirium was significant for oxybutynin (0.05, 95%CI 0.02–0.08) but not for solifenacin (−0.01, 95%CI −0.03 to 0.00). In addition, in the subgroup analyses, a statistically significant association of delirium was found for oxybutynin but not for solifenacin in the non‐dementia cohort (2.11,95% CI 1.08–4.13) and the dementia cohort (1.25, 95%CI 0.05–26.9). Conclusion The study found that oxybutynin but not solifenacin is associated with a risk of new‐onset delirium in older adults. The higher blockade of M1 and M2 receptors by oxybutynin is likely to contribute to delirium than solifenacin, which is highly selective for the M3 receptor subtype. Therefore, the treatment choice with an M3 selective agent must be given due consideration, particularly in those with pre‐existing cognitive impairment.
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Affiliation(s)
- Prasad S Nishtala
- Department of Pharmacy & Pharmacology, University of Bath, United Kingdom.,Centre for Therapeutic Innovation, University of Bath, United Kingdom
| | - Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Chinzowu T, Roy S, Nishtala PS. Antimicrobial-associated organ injury among the elderly: a systematic review and meta-analysis protocol. BMJ Open 2022; 12:e055210. [PMID: 35149569 PMCID: PMC8845168 DOI: 10.1136/bmjopen-2021-055210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Older adults (aged 65 years and above) constitute the fastest growing population cohort in the western world. There is increasing evidence that the burden of infections disproportionately affects this cohort of older adults and hence this vulnerable population is frequently exposed to antimicrobials. There is currently no systematic review summarising the evidence for risk of organ injury following antimicrobial exposure among older adults. This protocol will outline how we will conduct a systematic review and meta-analyses to examine the relationship between antimicrobial exposure and organ injury in older adults. METHODS AND ANALYSIS We will search for PsycINFO, PubMed and EMBASE databases for relevant articles using MeSH terms where applicable. After removing duplicates, articles will be screened for inclusion into or exclusion from the study by two reviewers. Title and abstract screening will be done first, followed by full-text screening. The Newcastle-Ottawa scale will be used to assess the risk of bias for cohort and case control studies, and the Cochrane collaboration's risk of bias tool will be used for randomised control trials. We will explore the potential sources of heterogeneity and bias using funnel and forest plots of the included studies. ETHICS AND DISSEMINATION During the conduct of the review, ethical principles will be observed to ensure integrity. Any potential conflicts of interests will be declared, all contributors acknowledged and no plagiarised material will be included in the review.The systematic review and meta-analysis will be submitted for publication in a peer-reviewed journal in geriatrics. The findings will also be presented at international conferences in geriatrics or pharmacoepidemiology. The results will be communicated to patient and public engagement networks supported by the NHS Research and Development. PROSPERO REGISTRATION NUMBER This protocol is registered in the PROSPERO database (registration number CRD42020152621).
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Affiliation(s)
| | - Sandipan Roy
- Department of Mathematical Science, University of Bath, Bath, UK
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
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18
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Bergler U, Ailabouni NJ, Pickering JW, Hilmer SN, Mangin D, Nishtala PS, Jamieson H. Deprescribing to reduce polypharmacy: study protocol for a randomised controlled trial assessing deprescribing of anticholinergic and sedative drugs in a cohort of frail older people living in the community. Trials 2021; 22:766. [PMID: 34732234 PMCID: PMC8564597 DOI: 10.1186/s13063-021-05711-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 10/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Targeted deprescribing of anticholinergic and sedative medications in older people may improve their health outcomes. This trial will determine if pharmacist-led reviews lead to general practitioners deprescribing anticholinergic and sedative medications in older people living in the community. METHODS AND ANALYSIS The standard protocol items: Recommendations for Interventional Trials (SPIRIT) checklist was used to develop and report the protocol. The trial will involve older adults stratified by frailty (low, medium, and high). This will be a pragmatic two-arm randomized controlled trial to test general practitioner uptake of pharmacist recommendations to deprescribe anticholinergic and sedative medications that are causing adverse side effects in patients. STUDY POPULATION Community-dwelling frail adults, 65 years or older, living in the Canterbury region of New Zealand, seeking publicly funded home support services or admission to aged residential care and taking at least one anticholinergic or sedative medication regularly. INTERVENTION New Zealand registered pharmacists using peer-reviewed deprescribing guidelines will visit participants at home in the community, review their medications, and recommend anticholinergic and sedative medications that could be deprescribed to the participant's general practitioner. The total use of anticholinergic and sedative medications will be quantified using the Drug Burden Index (DBI). OUTCOMES The primary outcome will be the change in total DBI between baseline and 6-month follow-up. Secondary outcomes will include entry into aged residential care, prolonged hospitalization, and death. DATA COLLECTION POINTS Data will be collected at the time of interRAI assessments (T0), at the time of the baseline review (T1), at 6 months following the baseline review (T2), and at the end of the study period, or end of study participation for participants admitted into aged residential care, or who died (T3). ETHICS AND DISSEMINATION Ethical approval has been obtained from the Human, Disability and Ethics Committee: ethical number (17CEN265). TRIAL REGISTRATION ClinicalTrials.gov ACTRN12618000729224 . Registered on May 2, 2018, with the Australian New Zealand Clinical Trials Registry.
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Affiliation(s)
- Ulrich Bergler
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Nagham J Ailabouni
- UniSA Clinical & Health Sciences, Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, Adelaide, South Australia
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Sarah N Hilmer
- Geriatric Pharmacology, Faculty of Medicine and Health, Northern Clinical School, Kolling Institute, University of Sydney and Royal North Shore Hospital, St Leonards, Australia
| | - Dee Mangin
- Department of Medicine, University of Otago, Christchurch, New Zealand.,David Braley and Nancy Gordon Chair in Family Medicine, McMaster University, Hamilton, Canada
| | | | - Hamish Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand. .,Burwood Hospital, Canterbury District Health Board, Christchurch, New Zealand.
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Chinzowu T, Roy S, Nishtala PS. Risk of antimicrobial-associated organ injury among the older adults: a systematic review and meta-analysis. BMC Geriatr 2021; 21:617. [PMID: 34724889 PMCID: PMC8561875 DOI: 10.1186/s12877-021-02512-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/10/2021] [Indexed: 11/24/2022] Open
Abstract
Background Older adults (aged 65 years and above) constitute the fastest growing population cohort in the western world. There is increasing evidence that the burden of infections disproportionately affects older adults, and hence this vulnerable population is frequently exposed to antimicrobials. There is currently no systematic review summarising the evidence for organ injury risk among older adults following antimicrobial exposure. This systematic review and meta-analysis examined the relationship between antimicrobial exposure and organ injury in older adults. Methodology We searched for original research articles in PubMed, Embase.com, Web of Science core collection, Web of Science BIOSIS citation index, Scopus, Cochrane Central Register of Controlled Trials, ProQuest, and PsycINFO databases, using key words in titles and abstracts, and using MeSH terms. We searched for all available articles up to 31 May 2021. After removing duplicates, articles were screened for inclusion into or exclusion from the study by two reviewers. The Newcastle-Ottawa scale was used to assess the risk of bias for cohort and case-control studies. We explored the heterogeneity of the included studies using the Q test and I2 test and the publication bias using the funnel plot and Egger’s test. The meta-analyses were performed using the OpenMetaAnalyst software. Results The overall absolute risks of acute kidney injury among older adults prescribed aminoglycosides, glycopeptides, and macrolides were 15.1% (95% CI: 12.8–17.3), 19.1% (95% CI: 15.4–22.7), and 0.3% (95% CI: 0.3–0.3), respectively. Only 3 studies reported antimicrobial associated drug-induced liver injury. Studies reporting on the association of organ injury and antimicrobial exposure by age or duration of treatment were too few to meta-analyse. The funnel plot and Egger’s tests did not indicate evidence of publication bias. Conclusion Older adults have a significantly higher risk of sustaining acute kidney injury when compared to the general adult population. Older adults prescribed aminoglycosides have a similar risk of acute kidney injury to the general adult population. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02512-3.
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Affiliation(s)
- Tichawona Chinzowu
- Department of Pharmacy and Pharmacology & Centre for Therapeutic Innovation, University of Bath, Bath, BA2 7AY, UK.
| | - Sandipan Roy
- Department of Mathematical Science, University of Bath, Bath, BA2 7AY, UK
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology & Centre for Therapeutic Innovation, University of Bath, Bath, BA2 7AY, UK
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20
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Chyou TY, Nishtala PS. Identifying frequent drug combinations associated with delirium in older adults: Application of association rules method to a case-time-control design. Pharmacoepidemiol Drug Saf 2021; 30:1402-1410. [PMID: 33991132 DOI: 10.1002/pds.5292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/28/2021] [Accepted: 05/11/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Older adults are at an increased risk of delirium because of age, polypharmacy, multiple comorbidities, frailty, and acute illness. Although medication-induced delirium in older adults is well understood, limited population-level evidence is available, particularly on combinations of medications associated with delirium in older adults. OBJECTIVES We aimed to apply association rule analysis to identify drug combinations contributing to delirium risk in adults aged 65 and older using a case-time-control design. METHOD We sourced a nationwide representative sample of New Zealander's aged ≥65 years from the pharmaceutical collections and hospital discharge information. Prescription records (2005-2015) were obtained from New Zealand pharmaceutical collections (Pharms). Medication exposures were coded as binary variables (exposed vs. not exposed) at the individual drug level. All medications, including antimicrobials, antihistamines, diuretics, opioids, and nonsteroidal anti-inflammatory medications, were considered drugs of interest. The first-time coded diagnosis of delirium was extracted from the National Minimal Dataset (NMDS). A unique patient identifier linked the prescription dataset to the event dataset to set up a case-time-control cohort, indexed at the first delirium event. Association rules were then applied to identify frequent drug combinations in the case and the control periods (l-day with a 35-day washout period) that are statistically associated with delirium, and the association was tested by computing a time-trend adjusted matched odds-ratio (MOR) and its 95% confidence interval (CI). RESULTS We identified 28 503 individuals (mean age 84.1 years) from 2005 to 2015 with delirium. Our combined association rule and case-time-control analysis identified several drug classes, including antipsychotics, benzodiazepines, opioids, and diuretics associated with delirium. Our analysis also identified frequently used drug combinations that are associated with delirium. Examples include combined exposures to quetiapine and furosemide (MOR = 6.17; 95%CI = [2.05-18.54]), haloperidol (MOR = 4.81; 95%CI = [3.16-6.69]), combined exposures to furosemide, omeprazole, and lorazepam (MOR = 3.94; 95%CI = [3.03-5.10]), and fentanyl exposure (MOR = 3.46; 95%CI [2.05-9.21]). CONCLUSION The association rule method applied to a case-time-control design is a novel approach to identifying drug combinations contributing to delirium with adjustment for any temporal trends in exposures. The study provides new insight into the combination of medicines linked to delirium.
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Affiliation(s)
- Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, Otago, New Zealand
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
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21
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Abey-Nesbit R, Peel NM, Matthews H, Hubbard RE, Nishtala PS, Bergler U, Deely JM, Pickering JW, Schluter PJ, Jamieson HA. Frailty of Māori, Pasifika, and Non-Māori/Non-Pasifika Older People in New Zealand: A National Population Study of Older People Referred for Home Care Services. J Gerontol A Biol Sci Med Sci 2021; 76:1101-1107. [PMID: 33075128 DOI: 10.1093/gerona/glaa265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Little is known about the prevalence of frailty in indigenous populations. We developed a frailty index (FI) for older New Zealand Māori and Pasifika who require publicly funded support services. METHODS An FI was developed for New Zealand adults aged 65 and older who had an interRAI Home Care assessment between June 1, 2012 and October 30, 2015. A frailty score for each participant was calculated by summing the number of deficits recorded and dividing by the total number of possible deficits. This created a FI with a potential range from 0 to 1. Linear regression models for FIs with ethnicity were adjusted for age and sex. Cox proportional hazards models were used to assess the association between the FI and mortality for Māori, Pasifika, and non-Māori/non-Pasifika. RESULTS Of 54 345 participants, 3096 (5.7%) identified as Māori, 1846 (3.4%) were Pasifika, and 49 415 (86.7%) identified as neither Māori nor Pasifika. New Zealand Europeans (48 178, 97.5%) constituted most of the latter group. Within each sex, the mean FIs for Māori and Pasifika were greater than the mean FIs for non-Māori and non-Pasifika, with the difference being more pronounced in women. The FI was associated with mortality (Māori subhazard ratio [SHR] 2.53, 95% CI 1.63-3.95; Pasifika SHR 6.03, 95% CI 3.06-11.90; non-Māori and non-Pasifika SHR 2.86, 95% CI 2.53-3.25). CONCLUSIONS This study demonstrated differences in FI between the ethnicities in this select cohort. After adjustment for age and sex, increases in FI were associated with increased mortality. This suggests that FI is predictive of poor outcomes in these ethnic groups.
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Affiliation(s)
| | - Nancye M Peel
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Hector Matthews
- Māori and Pacific Health, Canterbury District Health Board, Christchurch, New Zealand
| | - Ruth E Hubbard
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | | | - Ulrich Bergler
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Joanne M Deely
- Canterbury District Health Board, Christchurch, New Zealand
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Philip J Schluter
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia.,School of Health Sciences and Child Wellbeing Research Institute, University of Canterbury, Christchurch, New Zealand
| | - Hamish A Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand
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Tanana L, Latif A, Nishtala PS, Taylor D, Chen TF. An International Comparison of the Information in the Regulatory-Approved Drug Labeling and Prescribing Guidelines for Pediatric Depression. J Child Adolesc Psychopharmacol 2021; 31:294-309. [PMID: 33601936 DOI: 10.1089/cap.2020.0154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: To determine the differences in information between prescribing guidelines and drug labeling, as well as to compare the approval of psychotropic medicines for major depression in pediatric patients ("pediatric depression") across countries. Methods: The recommendations of The Maudsley Prescribing Guidelines in Psychiatry (MPGP) for the treatment of pediatric depression (<18 years) were compared against the regulatory-approved drug-labeling documents from the United Kingdom, Australia, New Zealand, Canada, and the United States. The use of medicines outside of their regulatory approval is defined as off-label use, so differences between the drug labeling and MPGP were characterized according to unapproved age, indication, dosage, or route of administration. Information in the drug labeling was also compared across countries. Results: MPGP provides recommendations for 6 medicines for the treatment of pediatric depression, for which, 30 drug labeling were retrieved. Three of 30 drug labeling were consistent with MPGP recommendations (fluoxetine in the United Kingdom, fluoxetine and escitalopram in the United States). Differences in information between MPGP and the drug labeling were identified in 26 of 30 drug labeling analyzed, most often due to age (24/26) followed by indication (2/26). No differences pertaining to dosage or route of administration information were identified. The number of approved psychotropic medicines varied across the studied countries and we found cross-country discrepancies in information in the drug labeling. Conclusion: Significant differences in information exists between MPGP and the drug labeling for psychotropic medicines for pediatric depression, due to unapproved ages or indications. Additionally, approval information in the drug labeling are not consistent across countries. Further research into reasons for variability and impact on practice may be warranted.
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Affiliation(s)
- Laila Tanana
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Asam Latif
- School of Health Sciences, Faculty of Medicine and Health Sciences, School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Prasad S Nishtala
- Department of Pharmacy & Pharmacology, University of Bath, Bath, United Kingdom
| | | | - Timothy F Chen
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Jamieson H, Abey-Nesbit R, Nishtala PS, Allore H, Han L, Deely JM, Pickering JW. Predictors of Residential Care Admission in Community-Dwelling Older People With Dementia. J Am Med Dir Assoc 2020; 21:1665-1670. [PMID: 32646821 PMCID: PMC7641960 DOI: 10.1016/j.jamda.2020.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objectives of this study were to identify variables associated with dementia and entry into aged residential care (ARC) and derive and validate a risk prediction model for dementia and entry into ARC. DESIGN This was an observational study of prospectively collected Home Care International Residential Assessment Instrument (interRAI-HC) assessment data. SETTING AND PARTICIPANTS Participants included all people age ≥65 years who had completed an interRAI-HC assessment between July 1, 2012 and June 30, 2018. Exclusion criteria included death or entry into ARC within 30 days of assessment and not living at home at the time of the assessment. MEASURES InterRAI data from 94,202 older New Zealanders were evaluated for presence or absence of dementia. A multivariable competing-risks model for entry into ARC with death as the competing event was used to estimate subdistribution hazard ratios (SHR). RESULTS In total, there were 18,672 (19.8%) persons with dementia (PWD). PWD were almost twice as likely to enter ARC as persons without dementia [42.8% vs 25.3%; difference 17.5% (95% confidence interval 16.7%‒18.2%)]. PWD at highest risk of entering ARC were those where there was a desire to live elsewhere (SHR 1.44), depression (indicated, SHR 1.15), poor cognitive performance (Cognitive Performance Scale minimal SHR 1.32 and severe plus SHR 1.91), and wandering (SHR 1.19). Factors associated with reduced risks of PWD entering ARC were living with a child or relative, alcohol consumption, and comorbidities. CONCLUSIONS AND IMPLICATIONS A desire to live elsewhere, social isolation, independent activities of daily living, and depression were independently associated with entry into ARC. Supporting caregivers may improve outcomes for PWD that delay entry into ARC. Future revisions of the interRAI questionnaire could provide more insight on this matter.
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Affiliation(s)
- Hamish Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand; Burwood Hospital, Christchurch, New Zealand.
| | | | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Heather Allore
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA; Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Ling Han
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Joanne M Deely
- Canterbury District Health Board, Christchurch, New Zealand; Research Management Office, Lincoln University, Lincoln, New Zealand
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
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24
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Nishtala PS, Gill S, Chyou TY. Analysis of the US FDA adverse event reporting system to identify adverse cardiac events associated with hydroxychloroquine in older adults. Pharmacoepidemiol Drug Saf 2020; 29:1689-1695. [PMID: 33078448 DOI: 10.1002/pds.5155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/01/2020] [Accepted: 10/14/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this study is to analyze the US FDA Adverse Event Reporting System (FAERS) to identify adverse cardiac events of hydroxychloroquine in older adults. METHOD A case/non-case method was used to determine adverse events associated with hydroxychloroquine as the primary suspect drug between January 1, 2004, and December 31, 2019, for older adults (≥65 years). Adverse events are preferred terms (PTs) defined in MedDRA. We used frequentist approaches, including the reporting odds ratio (ROR) and the proportional reporting ratio (PRR) to measure disproportionality. We used Bayesian approaches to derive information component (IC) value and Empirical Bayesian Geometric Mean (EBGM) score. Signals were defined as the number of reports > 3 and the lower limit of 95% confidence intervals (CI) of ROR ≥ 2, PRR ≥ 2, IC > 0, EBGM > 1. RESULTS We identified 334 adverse cardiac events comprising 71 different MedDRA PTs from 2004 to 2019 for hydroxychloroquine in older adults. Strong disproportionality signals were noted for "Restrictive cardiomyopathy" (ROR = 272.43 (138.09-537.47); EBGM = 149.78 (77.34-264.67), "Right ventricular hypertrophy" (219.49 (85.32-564.70); 102.74 (39.67-222.81), "Cardiac septal hypertrophy" (226.77 (78.65-653.80); 93.82 (32.19-219.81), "Myocardial fibrosis" (57.29 (21.06-155.85); 42.99 (14.74-100.75), and "Cardiotoxicity" (43.90 (26.66-72.27); 40.28 (24.02-63.72). CONCLUSIONS The risk of cardiomyopathy and myocardial disorders is high following exposure to hydroxychloroquine in older adults. Due to the current lack of safety data from randomized controlled trials as well as large observational studies to confirm the risk of adverse cardiac events associated with hydroxychloroquine, findings from analyses of post-marketing data may serve as interim guidance.
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Affiliation(s)
| | - Sakirat Gill
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Christodoulos IN, Chyou TY, Nishtala PS. Safety of fluoxetine use in children and adolescents: a disproportionality analysis of the Food and Drug Administration Adverse Event Reporting System (FAERS) database. Eur J Clin Pharmacol 2020; 76:1775-1776. [PMID: 32719920 DOI: 10.1007/s00228-020-02970-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
Affiliation(s)
| | - Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Prasad S Nishtala
- Department of Pharmacy & Pharmacology, University of Bath, Bath, BA2 7AY, UK.
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Chyou TY, Nishtala R, Nishtala PS. Comparative risk of Parkinsonism associated with olanzapine, risperidone and quetiapine in older adults-a propensity score matched cohort study. Pharmacoepidemiol Drug Saf 2020; 29:692-700. [PMID: 32301237 DOI: 10.1002/pds.5007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/09/2020] [Accepted: 03/29/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE The purpose of this study was to examine the incidence of Parkinsonism in new users of second-generation antipsychotics (SGAs) in older adults (≥65 years). In the secondary analyses, we examined the risk of Parkinsonism by type and dose of SGA and conducted age-sex interactions. METHOD This population-based study included older adults who had a new-onset diagnosis of Parkinsonism and who started taking olanzapine, risperidone or quetiapine between 1 January 2005, and 30 December 2016. The Cox proportional hazard (COXPH) model with inverse probability treatment weighted (IPTW) covariates was used to evaluate the risk of new-onset Parkinsonism associated with SGAs, using quetiapine as the reference. We used the Generalized Propensity Score method to evaluate the dose-response risk of Parkinsonism associated with SGAs. RESULTS After IPTW adjustment for covariates, the COXPH model showed that compared to quetiapine, the use of olanzapine and risperidone were associated with an increased risk of Parkinsonism. The IPTW-hazard ratios are 1.76 (95% confidence interval 1.57-1.97) and 1.31 (95%CI 1.16-1.49), respectively. The dose-response risk of Parkinsonism was highest for olanzapine with a hazard ratio of 1.69 (95%CI 1.40-2.05) and the least for quetiapine with a hazard ratio of 1.22 (95%CI 1.14-1.31). The risk of Parkinsonism in the 65 to 74-year age group was higher for both sexes with risperidone compared to olanzapine, but the risk increased with olanzapine for both sexes in the 85+ age group. CONCLUSION The study found that the risk of new-onset Parkinsonism in older adults is 31% and 76% higher with risperidone and olanzapine respectively compared to quetiapine.
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Affiliation(s)
- Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Nishtala PS, Chyou T. Identifying drug combinations associated with acute kidney injury using association rules method. Pharmacoepidemiol Drug Saf 2020; 29:467-473. [DOI: 10.1002/pds.4960] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 10/30/2019] [Accepted: 12/23/2019] [Indexed: 11/06/2022]
Affiliation(s)
| | - Te‐yuan Chyou
- Department of BiochemistryUniversity of Otago Dunedin Otago New Zealand
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Abstract
Objective: To summarize studies that used the international Resident Assessment home care instrument (interRAI HC) to examine study outcomes for older people. Methods: A comprehensive systematic search was performed to identify relevant studies, using five databases from 1990 until October 2016. The Cochrane Risk-Bias assessment tool and Newcastle-Ottawa Scale was used to assess the quality of RCTs and non-RCTs, respectively. Results: Based on the full-text analysis, 40 studies met the inclusion criteria out of 506 total records. The review included 6 RCTs, 2 quasi-experimental, 17 prospective and retrospective studies, 13 cross-sectional and 2 longitudinal studies. A series of interventions and/or applications were identified from this review that employed the use of interRAI HC instrument: (a) in health services, (b) as a new integrated care model and for implementing machine learning algorithm, (c) as a comprehensive geriatric assessment tool, (d) in case management, (e) for care planning and screening, (f) in drug therapy assessment, (g) to assess caregiver burden, and (h) for various risk assessments. Studies that employed the interRAI HC instrument reported an array of health-outcome measures mostly related to functional, cognition, hospitalization and mortality. Conclusions: Application of the interRAI HC tool varied markedly across all studies, and the outcomes measures were heterogeneous. Future research directions are discussed. Clinical Implications: The results from this study facilitate the use of interRAI HC as a tool to measure an intervention's effect that leads to improvements in specific geriatric-related health outcome measures emphasizes on functional status and quality of life and ascertain its utility as a quality indicator for the care of older individuals.
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Bala SS, Jamieson HA, Nishtala PS, Braund R. P4-626: ESTABLISHING GUIDELINES FOR ALTERNATIVES TO ANTICHOLINERGIC MEDICATIONS IN OLDER ADULTS WITH DEMENTIA. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.08.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Bala SS, Jamieson HA, Nishtala PS. Factors associated with inappropriate prescribing among older adults with complex care needs who have undergone the interRAI assessment. Curr Med Res Opin 2019; 35:917-923. [PMID: 30380343 DOI: 10.1080/03007995.2018.1543185] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
AIM To identify factors associated with prescribing potentially inappropriate medications (PIMs) in older adults (≥65 years) with complex care needs, who have undertaken a comprehensive geriatric risk assessment. METHODS A nationwide cross-sectional (retrospective, observational) study was performed. The national interRAI Home Care assessments conducted in New Zealand in 2015 for older adults were linked to the national pharmaceutical prescribing data (PHARMS). The 2015 Beers criteria were applied to the cross-matched data to identify the prevalence of PIMs. The factors influencing PIMs were analyzed using a multinomial logistic regression model. RESULTS In total, 16,568 older adults were included in this study. Individuals diagnosed with cancer, dementia, insomnia, depression, anxiety, and who were hospitalized in the last 90 days were more likely to be prescribed PIMs than those who were not diagnosed with the above disorders, and who were not hospitalized in the last 90 days. Individuals over 75 years of age, the Māori ethnic group among other ethnicities, individuals who were diagnosed with certain clinical conditions (diabetes, chronic obstructive pulmonary disease, stroke, or congestive cardiac failure), individuals requiring assistance with activities of daily living, and better self-reported health, were associated with a lesser likelihood of being prescribed PIMs. CONCLUSION The study emphasizes the identification of factors associated with the prescription of PIMs during the first completed comprehensive geriatric assessment. Targeted strategies to reduce modifiable factors associated with the prescription of PIMs in subsequent assessments has the potential to improve medication management in older adults.
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Affiliation(s)
- Sharmin S Bala
- a School of Preventive and Social Medicine, University of Otago , Dunedin , New Zealand
| | - Hamish A Jamieson
- b Department of Medicine , University of Otago , Christchurch , New Zealand
| | - Prasad S Nishtala
- c Department of Pharmacy and Pharmacology , University of Bath , Bath , UK
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Ailabouni N, Mangin D, Nishtala PS. DEFEAT-polypharmacy: deprescribing anticholinergic and sedative medicines feasibility trial in residential aged care facilities. Int J Clin Pharm 2019; 41:167-178. [PMID: 30659492 DOI: 10.1007/s11096-019-00784-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 01/09/2019] [Indexed: 12/17/2022]
Abstract
Background Prolonged use of anticholinergic and sedative medicines is correlated with worsening cognition and physical function decline. Deprescribing is a proposed intervention that can help to minimise polypharmacy whilst potentially improving several health outcomes in older people. Objective This study aimed to examine the feasibility of implementing a deprescribing intervention that utilises a patient-centred pharmacist-led intervention model; in order to address major deprescribing challenges such as general practitioner time constraints and lack of accessible deprescribing guidelines and processes. Setting Three residential care facilities. Methods The intervention involved a New Zealand registered pharmacist utilising peer-reviewed deprescribing guidelines to recommend targeted deprescribing of anticholinergic and sedative medicines to GPs. Main outcome measure The change in the participants' Drug Burden Index (DBI) total and DBI 'as required' (PRN) was assessed 3 and 6 months after implementing the deprescribing intervention. Results Seventy percent of potential participants were recruited for the study (n = 46), and 72% of deprescribing recommendations suggested by the pharmacist were implemented by General Pratitioners (p = 0.01; Fisher's exact test). Ninety-six percent of the residents agreed to the deprescribing recommendations, emphasising the importance of patient centred approach. Deprescribing resulted in a significant reduction in participants' DBI scores by 0.34, number of falls and adverse drug reactions, 6 months post deprescribing. Moreover, participants reported lower depression scores and scored lower frailty scores 6 months after deprescribing. However, cognition did not improve; nor did participants' reported quality of life. Conclusion This patient-centred deprescribing approach, demonstrated a high uptake of deprescribing recommendations and success rate. After 6 months, significant benefits were noted across a range of important health measures including mood, frailty, falls and reduced adverse reactions. This further supports deprescribing as a possible imperative to improve health outcomes in older adults.
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Affiliation(s)
| | - Dee Mangin
- University of Otago, Christchurch, New Zealand
- David Braley Nancy Gordon, Chair in Family Medicine, McMaster University, Hamilton, ON, Canada
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Bala SS, Jamieson HA, Nishtala PS. Determinants of prescribing potentially inappropriate medications in a nationwide cohort of community dwellers with dementia receiving a comprehensive geriatric assessment. Int J Geriatr Psychiatry 2019; 34:153-161. [PMID: 30251394 DOI: 10.1002/gps.5004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 09/08/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To identify the prevalence and predictors of prescribing potentially inappropriate medications (PIMs) in a nationwide cohort of community dwellers with dementia requiring complex care needs. METHODS A cross-matched data of the International Resident Assessment Instrument-Home Care (9.1) (interRAI-HC) and prescribing data obtained from the Pharmaceutical Claims Data Mart (Pharms) extract files for older adults (≥65 y) requiring complex care needs were utilized for this study. The 2015 Beers criteria were applied to identify the prevalence of PIMs in older adults with dementia. Sociodemographic and clinical predictors of PIMs were analysed using a logistic regression model. RESULTS The study population consisted of 16 568 individuals who had their first interRAI assessment from 1 January 2015 to 31 December 2015. The estimated prevalence of dementia was 13.2% (2190/16 568). 66.9% (1465/2190) of the older adults diagnosed with dementia were prescribed PIMs, of which anticholinergic medications constituted 59.6% (873/1465). Males and individuals who were prescribed a greater number of medications were more likely to be prescribed PIMs. Individuals over 85 years of age, Māori ethnic group of individuals, older adults who were being supervised with respect to their activities of daily living, and individuals who reported good or excellent self-reported health had a lesser likelihood of being prescribed PIMs. CONCLUSION We found that PIMs are prescribed frequently in older adults with dementia. Comprehensive geriatric assessments can serve as a potential tool to decrease the occurrence of PIMs in vulnerable groups with poor functional and cognitive status.
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Affiliation(s)
- Sharmin S Bala
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Hamish A Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
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Pouranayatihosseinabad M, Zaidi TS, Peterson G, Nishtala PS, Hannan P, Castelino R. The impact of residential medication management reviews (RMMRs) on medication regimen complexity. Postgrad Med 2018; 130:575-579. [PMID: 30091394 DOI: 10.1080/00325481.2018.1502016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES The primary objective of this study was to investigate the impact of RMMRs on medication regimen complexity, as assessed by a validated measure. METHODS Retrospective analysis of RMMRs pertaining to 285 aged care residents aged ≥ 65 years in Sydney, Australia. Medication regimen complexity was measured using the Medication Regimen Complexity Index (MRCI) at baseline, after pharmacists' recommendations (assuming that all of the pharmacists' recommendations were accepted by the General Practitioner (GP)), and after the actual uptake of pharmacists' recommendations by the GP. Differences in the regimen complexity was measured using the Wilcoxon sign rank test. RESULTS Pharmacists made 764 recommendations (average 2.7 recommendations per RMMR), of which 569 (74.5%) were accepted by GPs. The median MRCI at baseline in the sample was 25.5 (IQR = 19.0-32.5). No statistically significant differences were demonstrated in the MRCI scores after pharmacists' recommendations (p = 0.53) or after GPs' acceptance of these recommendations (p = 0.07) compared to the baseline. CONCLUSION Our study revealed high acceptance of pharmacists' recommendations by GPs. This suggests that RMMRs are useful for identifying and resolving drug-related issues among residents of ACFs. However, our study failed to show a significant effect of RMMRs in reducing the medication regimen complexity, as measured by the MRCI. Further studies are needed to establish the association of medication regimen complexity and clinical outcomes in residents of ACFs.
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Affiliation(s)
| | | | - Gregory Peterson
- a University of Tasmania School of Pharmacy , Hobart , Australia
| | - Prasad S Nishtala
- b University of Otago New Zealand's National School of Pharmacy , Dunedin , New Zealand
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Jamieson HA, Nishtala PS, Scrase R, Deely JM, Abey-Nesbit R, Hilmer SN, Abernethy DR, Berry SD, Mor V, Lacey CJ, Schluter PJ. Drug Burden Index and Its Association With Hip Fracture Among Older Adults: A National Population-Based Study. J Gerontol A Biol Sci Med Sci 2018; 74:1127-1133. [DOI: 10.1093/gerona/gly176] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Hamish A Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Older Persons Health Specialist Service, Burwood Hospital, Christchurch, New Zealand
| | | | - Richard Scrase
- Department of Nursing, Canterbury District Health Board, Christchurch, New Zealand
| | - Joanne M Deely
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Sarah N Hilmer
- Cognitive Decline Partnership Centre, Ageing and Pharmacology, Kolling Institute of Medical Research, School of Medicine, University of Sydney, St Leonards, NSW, Australia
| | - Darrell R Abernethy
- Drug Safety Office of Clinical Pharmacology, U.S. FDA, U.S. Department of Health and Human Services, Baltimore, Maryland
| | - Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, Massachusetts
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University, School of Public Health, Providence, Rhode Island
| | - Cameron J Lacey
- Department of Medicine, University of Otago, Christchurch, New Zealand
- West Coast District Health Board, Greymouth
| | - Philip J Schluter
- School of Health Sciences, College of Education, Health and Human Development University of Canterbury, Christchurch, New Zealand
- Primary Care Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, Australia
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Ailabouni N, Tordoff J, Mangin D, Nishtala PS. Do Residents Need All Their Medications? A Cross-Sectional Survey of RNs' Views on Deprescribing and the Role of Clinical Pharmacists. J Gerontol Nurs 2018; 43:13-20. [PMID: 28945268 DOI: 10.3928/00989134-20170914-05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A cross-sectional survey was mailed to 307 RNs of a nationally representative sample of residential aged care facilities to investigate their views and perceptions on medication use and deprescribing in older adults. Questions were grouped according to each stage of the medication use process, and a dedicated section to explore nurses' views on deprescribing was included. Ninety-one questionnaires were received, yielding a 29.6% response rate. Respondents highlighted several challenges including achieving medication reconciliation for new residents, access to physicians to admit patients in a timely fashion, and issues pertaining to lack of clear medical information transcribing when transferring patients between health care settings. More than one half (67.4%) of nurses agreed or strongly agreed that deprescribing implemented with the help of a clinical pharmacist would be beneficial to residents and could improve medication adherence (44%), benefit residents' quality of life (50.5%), and reduce the length of time spent by nurses on medication administration (35.2%). Increased awareness regarding polypharmacy and potential deprescribing benefits is necessary to improve appropriate prescribing and medication use. [Journal of Gerontological Nursing, 43(10), 13-20.].
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Nishtala PS, Chyou TY, Held F, Le Couteur DG, Gnjidic D. Association rules method and big data: Evaluating frequent medication combinations associated with fractures in older adults. Pharmacoepidemiol Drug Saf 2018; 27:1123-1130. [DOI: 10.1002/pds.4432] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/03/2018] [Accepted: 03/06/2018] [Indexed: 11/08/2022]
Affiliation(s)
| | - Te-yuan Chyou
- School of Pharmacy; University of Otago; Dunedin Otago New Zealand
| | - Fabian Held
- Charles Perkins Centre; University of Sydney; Sydney NSW Australia
| | - David G. Le Couteur
- Centre for Education and Research on Ageing, Ageing and Alzheimers Institute, Concord Hospital; The University of Sydney; Sydney NSW Australia
- Faculty of Pharmacy; The University of Sydney; Sydney NSW Australia
| | - Danijela Gnjidic
- Charles Perkins Centre; University of Sydney; Sydney NSW Australia
- Faculty of Pharmacy; The University of Sydney; Sydney NSW Australia
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Narayan SW, Nishtala PS. Population-based study examining the utilization of preventive medicines by older people in the last year of life. Geriatr Gerontol Int 2018; 18:892-898. [DOI: 10.1111/ggi.13273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/02/2017] [Accepted: 12/21/2017] [Indexed: 01/28/2023]
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Bala SS, Narayan SW, Nishtala PS. Potentially inappropriate medications in community-dwelling older adults undertaken as a comprehensive geriatric risk assessment. Eur J Clin Pharmacol 2018; 74:645-653. [PMID: 29330585 DOI: 10.1007/s00228-018-2412-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 01/03/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE The prescription of potentially inappropriate medications (PIMs) is associated with an increase in adverse events, prescribing cascades, high health-care costs, morbidity, and mortality in the elderly. The overarching objective of this study is to examine the prevalence of PIMs in the elderly, applying the 2012 American Geriatrics Society Beers criteria for the study period 2012-2014, and the updated 2015 Beers criteria for 2015. METHODS The study population (N = 70,479) included a continuously recruited national cohort of community-dwelling older (aged ≥ 65 years) New Zealanders who had undertaken the International Resident Assessment Instrument-Home Care (interRAI-HC) assessments between September 2012 and October 2015. Exposure of PIMs 90 days before and after assessment, and 90-180 days after assessment are reported. RESULTS Exposure to PIMs was highest in individuals aged over 95 years and in males. The average number of PIMs prescribed 90 days before assessment during the period 2015 was marginally higher compared to 2012-2014 (0.19 versus 0.04), and a greater number of individuals were exposed to one or more PIMs in 2015 compared to 2012-2014 (7.13 versus 2.17%). The prevalence of PIMs 90 days before and after assessment was 2.17 and 6.92% for 2012-2014, and 7.13 and 24.7% for 2015, respectively. The percent change in PIMs in 2012-2014 and 2015 after 90 days of assessment were 4.70% (confidence interval (CI) 4.50%, 5.00%, p < 0.001) and 17.60% (95% CI 16.80%, 18.30%, p < 0.001), respectively. The majority of PIMs prescribed belonged to the therapeutic class of medications acting on the central nervous system and the gastrointestinal system. CONCLUSION Geriatric risk assessments may provide a vital opportunity to review medication lists by multidisciplinary teams with a view to reducing PIMs and unnecessary polypharmacy in older adults. Comprehensive geriatric risk assessment has the potential to reduce adverse medication outcomes and costs associated with inappropriate prescribing in a vulnerable population of older adults.
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Affiliation(s)
- Sharmin S Bala
- New Zealand's National School of Pharmacy, University of Otago, Dunedin, New Zealand.
| | - Sujita W Narayan
- New Zealand's National School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Prasad S Nishtala
- New Zealand's National School of Pharmacy, University of Otago, Dunedin, New Zealand
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Narayan SW, Hilmer SN, Nishtala PS. A population-level study examining discontinuation of statins in older people with dementia. Eur J Clin Pharmacol 2017; 74:379-381. [PMID: 29192380 DOI: 10.1007/s00228-017-2390-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/27/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Sujita W Narayan
- School of Pharmacy, University of Otago, P O Box 56, Dunedin, 9054, New Zealand.
| | - Sarah N Hilmer
- Kolling Institute of Medical Research, Royal North Shore Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Prasad S Nishtala
- School of Pharmacy, University of Otago, P O Box 56, Dunedin, 9054, New Zealand
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Abstract
AIM To evaluate the National Minimum Data Set (NMDS) against the International Resident Assessment Instrument-Home Care (interRAI-HC) in diagnosing dementia or Parkinson disease (PD). METHOD The NMDS data were matched with interRAI-HC for all older individuals in New Zealand. Dementia or PD was compared within 90 and 180 days and 1 to 4 years preceding and subsequent to the date of diagnosis in interRAI-HC. Consistency was measured through sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), weighted kappa (κ), and McNemar test. RESULTS For a diagnosis within 90 days, dementia showed 60.77% sensitivity, 95.33% specificity, 68.46% PPV, and 93.58% NPV. The PD showed 65.74% sensitivity, 99.52% specificity, 80.43% PPV, and 98.98% NPV. κ for dementia (κ = 0.59), PD (κ = 0.720), and McNemar test was significant ( P < .001) for all lengths of follow-up. CONCLUSION Substantial agreement between multiple sources of health data can be a valuable resource for decision-making in older people with neurological conditions.
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Affiliation(s)
| | - Hamish A Jamieson
- 2 Department of Medicine, University of Otago, Christchurch, New Zealand
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Narayan SW, Nishtala PS. Development and validation of a Medicines Comorbidity Index for older people. Eur J Clin Pharmacol 2017; 73:1665-1672. [DOI: 10.1007/s00228-017-2333-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/04/2017] [Indexed: 01/10/2023]
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Narayan SW, Nishtala PS. Discontinuation of Preventive Medicines in Older People with Limited Life Expectancy: A Systematic Review. Drugs Aging 2017; 34:767-776. [DOI: 10.1007/s40266-017-0487-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Narayan SW, Nishtala PS. Antihypertensive medicines utilization: A decade-long nationwide study of octogenarians, nonagenarians and centenarians. Geriatr Gerontol Int 2017; 17:1109-1117. [DOI: 10.1111/ggi.12838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/23/2016] [Accepted: 04/27/2016] [Indexed: 11/30/2022]
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Bachmann CJ, Aagaard L, Bernardo M, Brandt L, Cartabia M, Clavenna A, Coma Fusté A, Furu K, Garuoliené K, Hoffmann F, Hollingworth S, Huybrechts KF, Kalverdijk LJ, Kawakami K, Kieler H, Kinoshita T, López SC, Machado-Alba JE, Machado-Duque ME, Mahesri M, Nishtala PS, Piovani D, Reutfors J, Saastamoinen LK, Sato I, Schuiling-Veninga CCM, Shyu YC, Siskind D, Skurtveit S, Verdoux H, Wang LJ, Zara Yahni C, Zoëga H, Taylor D. International trends in clozapine use: a study in 17 countries. Acta Psychiatr Scand 2017; 136:37-51. [PMID: 28502099 DOI: 10.1111/acps.12742] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE There is some evidence that clozapine is significantly underutilised. Also, clozapine use is thought to vary by country, but so far no international study has assessed trends in clozapine prescribing. Therefore, this study aimed to assess clozapine use trends on an international scale, using standardised criteria for data analysis. METHOD A repeated cross-sectional design was applied to data extracts (2005-2014) from 17 countries worldwide. RESULTS In 2014, overall clozapine use prevalence was greatest in Finland (189.2/100 000 persons) and in New Zealand (116.3/100 000), and lowest in the Japanese cohort (0.6/100 000), and in the privately insured US cohort (14.0/100 000). From 2005 to 2014, clozapine use increased in almost all studied countries (relative increase: 7.8-197.2%). In most countries, clozapine use was highest in 40-59-year-olds (range: 0.6/100 000 (Japan) to 344.8/100 000 (Finland)). In youths (10-19 years), clozapine use was highest in Finland (24.7/100 000) and in the publicly insured US cohort (15.5/100 000). CONCLUSION While clozapine use has increased in most studied countries over recent years, clozapine is still underutilised in many countries, with clozapine utilisation patterns differing significantly between countries. Future research should address the implementation of interventions designed to facilitate increased clozapine utilisation.
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Affiliation(s)
| | - L Aagaard
- Life Science Team, Bech-Bruun Law Firm, Copenhagen, Denmark
| | - M Bernardo
- Barcelona Clinic Schizophrenia Unit, Neuroscience Institute, and Hospital Clínic, Department of Medicine, Barcelona University, and Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - L Brandt
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Cartabia
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - A Clavenna
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - A Coma Fusté
- Pharmacy Department of Barcelona Health Region, Catalan Health Service (CatSalut), Barcelona, Spain
| | - K Furu
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - K Garuoliené
- Medicines Reimbursement Department, National Health Insurance Fund of the Republic of Lithuania, Vilnius, Lithuania.,Faculty of Medicine, Department of Pathology, Forensic Medicine and Pharmacology, Vilnius University, Vilnius, Lithuania
| | - F Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - S Hollingworth
- School of Pharmacy, University of Queensland, Woolloongabba, Qld, Australia
| | - K F Huybrechts
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - L J Kalverdijk
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, the Netherlands
| | - K Kawakami
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - H Kieler
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - T Kinoshita
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - S C López
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - J E Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - M E Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - M Mahesri
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P S Nishtala
- New Zealand's National School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - D Piovani
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - J Reutfors
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - L K Saastamoinen
- Kela Research, The Social Insurance Institution, Helsinki, Finland
| | - I Sato
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - C C M Schuiling-Veninga
- Unit of Pharmacotherapy, -Epidemiology and -Economics, Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Y-C Shyu
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan.,Institute of Molecular Biology, Academia Sinica, Taipei, Qld, Taiwan.,Department of Nutrition, Chang Gung University of Science and Technology, Kwei-Shan, Taiwan
| | - D Siskind
- School of Medicine, University of Queensland, Woolloongabba, Qld, Australia
| | - S Skurtveit
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - H Verdoux
- University Bordeaux, INSERM, Bordeaux Population Health Research Center, team Pharmaco-epidemiology, UMR 1219, F-33000, Bordeaux, France
| | - L-J Wang
- Department of Child & Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C Zara Yahni
- Pharmacy Department of Barcelona Health Region, Catalan Health Service (CatSalut), Barcelona, Spain
| | - H Zoëga
- Bordeaux Population Health Research Center, INSERM, Univ. Bordeaux, team Pharmaco-epidemiology, UMR 1219, Bordeaux, France
| | - D Taylor
- South London and Maudsley NHS Foundation Trust, London, UK.,Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Abstract
INTRODUCTION Targeted deprescribing of anticholinergic and sedative medicines can lead to positive health outcomes in older people; as they have been associated with cognitive and physical functioning decline. This study will examine whether the proposed intervention is feasible at reducing the prescription of anticholinergic and sedative medicines in older people. METHODS AND ANALYSIS The Standard Protocol Items: Recommendations for Interventional trials (SPIRIT checklist) was used to develop and report the protocol. Single group (precomparison and postcomparison) feasibility study design. STUDY POPULATION 3 residential care homes have been recruited. INTERVENTION This will involve a New Zealand registered pharmacist using peer-reviewed deprescribing guidelines, to recommend to general practitioners (GPs), sedative and anticholinergic medicines that can be deprescribed. The cumulative use of anticholinergic and sedative medicines for each participant will be quantified, using the Drug Burden Index (DBI). OUTCOMES The primary outcome will be the change in the participants' DBI total and DBI PRN 3 and 6 months after implementing the deprescribing intervention. Secondary outcomes will include the number of recommendations taken up by the GP, participants' cognitive functioning, depression, quality of life, activities of daily living and number of falls. DATA COLLECTION POINTS Participants' demographic and clinical data will be collected at the time of enrolment, along with the DBI. Outcome measures will be collected at the time of enrolment, 3 and 6 months' postenrolment. ETHICS AND DISSEMINATION Ethics approval has been granted by the Human Disability and Ethics Committee. Ethical approval number (16/NTA/61). TRIAL REGISTRATION NUMBER Pre-results; ACTRN12616000721404.
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Affiliation(s)
| | - Dee Mangin
- University of Otago, Christchurch and David Braley Nancy Gordon, Chair in Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Nishtala PS, Chyou TY. Zopiclone Use and Risk of Fractures in Older People: Population-Based Study. J Am Med Dir Assoc 2017; 18:368.e1-368.e8. [DOI: 10.1016/j.jamda.2016.12.085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 12/30/2016] [Accepted: 12/30/2016] [Indexed: 11/27/2022]
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Nishtala PS, Jamieson HA. New Zealand's interRAI: A Resource For Examining Health Outcomes in Geriatric Pharmacoepidemiology. J Am Geriatr Soc 2017; 65:876-877. [DOI: 10.1111/jgs.14778] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Venäläinen O, Bell JS, Kirkpatrick CM, Nishtala PS, Liew D, Ilomäki J. Adverse Drug Reactions Associated With Cholinesterase Inhibitors—Sequence Symmetry Analyses Using Prescription Claims Data. J Am Med Dir Assoc 2017; 18:186-189. [DOI: 10.1016/j.jamda.2016.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/08/2016] [Indexed: 01/22/2023]
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Ndukwe HC, Nishtala PS. Glucose monitoring in new users of second-generation antipsychotics in older people. Arch Gerontol Geriatr 2017; 70:136-140. [PMID: 28131975 DOI: 10.1016/j.archger.2017.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/05/2017] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Treatment guidelines published world-wide have highlighted concerns of increased metabolic risks associated with second-generation antipsychotics (SGAs). The aim of the study was to evaluate blood glucose monitoring rates for SGA new users in older people aged 65 years and above during the study period 2006-2012, and investigate the pre-post 2007 Best Practice Advocacy Centre's (bpacnz) glucose monitoring recommendation in New Zealand. METHODS The study was a population-based retrospective cohort of SGA new users (365days without pre-exposure to antipsychotics). Pharmaceutical collections data were extracted and used to identify older people dispensed SGAs and linked to the National Minimum Dataset and Laboratory Claims collection. WHO Methodology's Anatomical Therapeutic Chemical method's classification was used to characterise the SGAs dispensed. RESULTS Of the 25,603 new users dispensed SGAs, 63.5% received glycaemic control monitoring at least once during the study period. Of these, only 20.1% were monitored at baseline, 38.7% were monitored for glycaemic control within the first 90 days. Glycaemic control monitoring within the first 180days increased to more than half (57.5%) of the SGA new users. Proportion of individuals monitored were independent (χ2=6.1; P=0.4) of pre-post bpacnz recommendation. CONCLUSIONS Blood glucose monitoring was underutilized in new SGA users. No significant improvement in glycaemic control monitoring was observed after the 2007 bpacnz consensus statement release at baseline, 90days and at 180 days. Prescribers must be cautioned about the metabolic risks posed by SGAs and recommend glycaemic control monitoring.
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Affiliation(s)
- Henry C Ndukwe
- School of Pharmacy, P.O. Box 56, University of Otago, Dunedin, New Zealand.
| | - Prasad S Nishtala
- School of Pharmacy, P.O. Box 56, University of Otago, Dunedin, New Zealand.
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Ndukwe HC, Wang T, Tordoff JM, Croucher MJ, Nishtala PS. Geographic variation in psychotropic drug utilisation among older people in New Zealand. Australas J Ageing 2016; 35:242-248. [PMID: 26991493 DOI: 10.1111/ajag.12298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To examine psychotropic drug utilisation in older people in New Zealand by age, sex, health board domicile and deprivation status. METHODS A repeated cross-sectional analysis of population-based drug utilisation data stratified by age, sex, ethnicity, health board and deprivation status was conducted from 2005 to 2013. RESULTS Psychotropic utilisation increased between 2005 and 2013 (ranging from 7.0 to 74.0%) across all the health boards. In people aged 85 years and above, the hypnotic and sedative prevalence ratio compared to the 65- to 69-year age group was 1.45 (95% CI 1.44, 1.46). Between 2005 and 2013, the antidepressants prevalence ratio increased (1.27 (95% CI 1.22, 1.33)) relative to anxiolytics. CONCLUSIONS Overall psychotropic drug utilisation increased over time. Despite safety concerns, hypnotic and sedative utilisation increased in the oldest vulnerable group. Shifts from anxiolytics to antidepressants in some health boards were consistent with guidelines for extended indications of antidepressant drug use.
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Affiliation(s)
- Henry C Ndukwe
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Ting Wang
- Department of Mathematics and Statistics, University of Otago, Dunedin, New Zealand
| | - June M Tordoff
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Matthew J Croucher
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
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