Prescribing and deprescribing in very old age: perceptions of very old adults, caregivers and health professionals

BACKGROUND

although they are major consumers of medications, there is little evidence-based data to guide prescribing and deprescribing of medications for very old adults (80+ years).

OBJECTIVES

to discover the perceptions of very old adults, caregivers and health professionals in order to further examine the clinical and ethical issues raised by prescribing and deprescribing in very old age.

METHODS

individual interviews were conducted with very old adults (n = 10) and caregivers (n = 6), whereas group interviews were conducted with health professionals (n = 11). The themes covered included perceptions of medication use, polypharmacy, deprescribing and patient-health professional relationships. Thematic analysis was used to identify areas of convergence and divergence.

RESULTS

very old adults are satisfied with the medications they are taking, do not see the need to reduce their medication use and consider their doctor as the expert who should make the decisions regarding treatment. The perceptions of caregivers are similar to those of older adults, whereas health professionals believe that very old adults take a lot of inappropriate medications and list multiple barriers to deprescribing. All participants describe a normalisation of medication use with ageing.

CONCLUSION

there is a dichotomy between the perception of the very old adults/caregivers and that of health professionals regarding the safety of medication in very old age. A cultural change regarding medication use seems essential to optimise therapy and support deprescribing in clinical practice since the potential issues raised by researchers do not resonate with the main stakeholders.

Associations of Wellbeing Levels, Changes, and Within-Person Variability With Late-Life All-Cause Mortality Across 12 Years: Contrasting Hedonic vs. Eudaimonic Wellbeing Among Very Old Adults

Advanced old age has been characterized as a biologically highly vulnerable life phase. Biological, morbidity-, and cognitive impairment-related factors play an important role as mortality predictors among very old adults. However, it is largely unknown whether previous findings confirming the role of different wellbeing domains for mortality translate to survival among the oldest-old individuals. Moreover, the distinction established in the wellbeing literature between hedonic and eudaimonic wellbeing as well as the consideration of within-person variability of potentially relevant mortality predictors has not sufficiently been addressed in prior mortality research. In this study, we examined a broad set of hedonic and eudaimonic wellbeing indicators, including their levels, their changes, as well as their within-person variability, as predictors of all-cause mortality in a sample of very old individuals. We used data from the LateLine study, a 7-year longitudinal study based on a sample of n = 124 individuals who were living alone and who were aged 87–97 years (M = 90.6, SD = 2.9) at baseline. Study participants provided up to 16 measurement occasions (mean number of measurement occasions per individual = 5.50, SD = 4.79) between 2009 and 2016. Dates of death were available for 118 individuals (95.2%) who had deceased between 2009 and 2021. We ran longitudinal multilevel structural equation models and specified between-person level differences, within-person long-term linear change trends, as well as the “detrended” within-person variability in three indicators of hedonic (i.e., life satisfaction and positive and negative affect) and four indicators of eudaimonic wellbeing (i.e., purpose in life, autonomy, environmental mastery, and self-acceptance) as all-cause mortality predictors. Controlling for age, gender, education, and physical condition and testing our sets of hedonic and eudaimonic indictors separately in terms of their mortality impact, solely one eudaimonic wellbeing indicator, namely, autonomy, showed significant effects on survival. Surprisingly, autonomy appeared “paradoxically” related with mortality, with high individual levels and intraindividual highly stable perceptions of autonomy being associated with a shorter residual lifetime. Thus, it seems plausible that accepting dependency and changing perceptions of autonomy over time in accordance with objectively remaining capabilities might become adaptive for survival in very old age.

Immune Thrombocytopenia in a Very Elderly Patient With Covid-19

Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a decreased number of platelets and mucocutaneous bleeding. Many viruses have been identified as triggers of the autoimmune process, including human immunodeficiency virus (HIV), hepatitis C virus (HCV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), parvovirus, rubella, and measles. Association with the new severe acute respiratory syndrome coronavirus, SARS-CoV-2 infection (Covid-19 infection) has been rarely reported. Here, we report the oldest case of ITP patient triggered by the novel coronavirus infection. He showed inadequate response to IVIG but responded to corticosteroids with no severe adverse events. Further studies are warranted to determine the optimal therapeutic strategies for ITP with the Covid-19 infection.

Risk factors for uroseptic shock in hospitalized patients aged over 80 years with urinary tract infection

Background

The purpose of this study was to compare clinical characteristics and outcomes in individuals of different age groups with urinary tract infection (UTI), and to identify the relationships among advanced age and uroseptic shock.

Methods

This retrospective study compared clinical characteristics and outcomes in patients in different age groups with UTI and identified relationships between advanced age and uroseptic shock among hospitalized patients with UTI in an acute hospital care setting from January 2006 to October 2018. Patients were divided into young (age below 65 years), old (65–80 years), and very old (above 80 years) groups.

Results

Of 1,043 participants, 269 (25.8%) were very old and 200 (19.2%) developed uroseptic shock. Very old age [odds ratio (OR) 1.99, 95% confidence interval (CI): 1.25–3.19, P=0.004], male (OR 1.54, 95% CI: 1.07–2.24, P=0.022), presented flank pain (OR 1.54, 95% CI: 1.05–2.24, P=0.025), congestive heart failure (CHF) (OR 2.54, 95% CI: 1.27–5.06, P=0.008), acute kidney injury (AKI) (OR 4.19, 95% CI: 2.78–6.30, P<0.001), bacteremia (OR 1.78, 95% CI: 1.25–2.53, P=0.001), and multiple drug-resistant (MDR) bacteria (OR 1.43, 95% CI: 1.02–2.00, P=0.039) were associated with an increased risk of uroseptic shock in patients with UTI. In very old patients with UTI, bacteremia (OR 2.54, 95% CI: 1.38–4.69, P=0.003) and AKI (OR 4.37, 95% CI: 2.15–8.90, P<0.001) were independently associated with uroseptic shock.

Conclusions

Very old patients with UTI had a higher risk of developing uroseptic shock than younger patients. Bacteremia was an independent risk factor for uroseptic shock in very old patients with UTI.