364 research outputs found
Optimizing medication use in older adults with multimorbidity and polypharmacy.
No full textBackground
Globally, societies are ageing. In Switzerland, the population group of adults aged ≥ 65 years is projected to increase from around 17% in 2010 to a third of the population by the year 2050. With ageing societies also come increasing numbers of older adults with chronic conditions. This is mainly due to the fact that certain diseases are more prevalent in older age. With multimorbidity often comes the concurrent use of multiple medications, as patients usually use different medications to manage their different chronic conditions. Patients with polypharmacy are at a higher risk of having inappropriate polypharmacy, which can be a result of both over- and under-prescribing. They are at a higher risk of using potentially inappropriate medications (PIMs), which are medications for which the risk of adverse events outweighs the clinical benefit. While appropriate polypharmacy has a positive effect on patients’ health status, inappropriate polypharmacy and the use of PIMs may have detrimental effects. Due to this, there is the need to regularly review, and if necessary, to optimize the medication use of older adults with multimorbidity and polypharmacy. For different reasons, however, efforts to perform medication reviews in this patient group have been difficult to implement. First, many research efforts have focused on older adults in general or older adults with specific chronic conditions, which is why systematic evidence on the use of PIMs in older adults with multimorbidity and polypharmacy is scarce. Second, medication optimization, and in particular deprescribing, is challenging due to different types of barriers faced by GPs and patients, which result in medication optimization interventions being difficult to translate into clinical practice. Third, conducting clinical research with older adults with multimorbidity and polypharmacy and general practitioners with the aim of optimizing medication use can be challenging. In general, older and multimorbid patients are commonly underrepresented in clinical research. Additionally, only a small share of clinical research takes place in the primary care setting.
Aims
The overall objective of this thesis was to study different aspects related to the optimization of medication use in older patients with polypharmacy and multimorbidity. More specifically, this thesis had three different aims; (1) to investigate the use of PIMs in adults aged ≥ 65 years with multimorbidity and polypharmacy as well as to explore the factors associated with the new prescribing of PIMs in this patient group; (2) to investigate general practitioners’ (GPs) willingness to make deprescribing decisions in older patients with polypharmacy and to examine which patient characteristics are associated with a higher likelihood of making deprescribing decisions; and (3) to explore the conduct of the ‘Optimizing PharmacoTherapy In the Multimorbid Elderly in Primary Care’ (OPTICA) trial in more depth. One the one hand, this entailed comparing the baseline characteristics of GPs and patients from the OPTICA trial with reference cohorts from a Swiss real-world cohort to establish the representativeness of the trial participants. On the other hand, this entailed performing a mixed-methods analysis of the use and implementation of the ‘Systematic Tool to Reduce Inappropriate Prescribing’ (STRIP) assistant, a new electronic clinical decision support system (CDSS) developed in the Netherlands, during the OPTICA trial.
Methods
A series of quantitative and mixed-methods studies were conducted to investigate the different aspects related to the optimization of medication use in older patients with polypharmacy and multimorbidity. To study Aim I, I used a dataset with linked Medicare claims and data from electronic health records from seven hospitals and medical centers in the Boston metropolitan area (RPDR-CMS dataset), which covered the period from 2007 to 2014. Using this data I explored the use of PIMs, defined with the 2019 version of the Beers criteria, in adults aged ≥ 65 years, with ≥ 2 chronic conditions, and ≥ 5 long-term medications. I performed cross-sectional analyses and a retrospective cohort study. I analyzed the retrospective cohort study using Cox regression analysis. For Aim II, I collected and analyzed cross-sectional data from more than 1700 GPs in 31 countries. In this questionnaire we presented hypothetical case-vignettes to GPs, which differed in terms of patient characteristics, and for each case-vignette we asked GPs if they would deprescribe any of the medications and if so, which ones. For Aim III, I performed descriptive analyses to describe the trial participants, including patients’ willingness to have medications deprescribed, and to assess the representativeness of participant characteristics in the OPTICA trial and I conducted an explanatory mixed-methods study. In the descriptive analysis, I compared the characteristics of patients and GPs participating in the OPTICA trial to those the ‘Family medicine ICPC Research using Electronic medical records’ (FIRE) project, which is a database with data from electronic health records from around 700 GPs in the Swiss German part of Switzerland and thus constitutes a real-world cohort. In the mixed-methods study we first collected quantitative data, which we then sought to further explain and understand through qualitative data collection. In the qualitative interviews we explored questions related to the barriers and facilitators linked to using the STRIP assistant during the OPTICA trial.
Results
For Aim I, I found that >69% of older patients with multimorbidity and polypharmacy used ≥ 1 PIMs from 2007 to 2014. Central nervous system drugs and gastrointestinal drugs were found to be the most commonly used PIMs. More than 10% of medication costs were spent on potentially inappropriate medications. Furthermore, I found that 2.5% of PIM-naïve1 older adults with polypharmacy and multimorbidity were prescribed a PIM during the 90-day follow-up period. Male sex (Hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.06-1.57, reference: female sex), the number of ambulatory visits (18-29 visits: HR = 1.42, 95% CI 1.06-1.92; ≥ 30: HR = 2.12, 95% CI 1.53-2.95, reference: ≤ 9 visits), the number of prescribing orders (HR = 1.02 per unit increase, 95% CI 1.01-1.02), and heart failure (HR = 1.38, 95% CI 1.07-1.78, reference: no heart failure diagnosis) were independently associated with a higher risk of being newly prescribed a PIM. Higher age was independently associated with a lower risk of being newly prescribed a PIM (85 years: HR = 0.75, 95% CI 0.56-0.99, reference: 65-74 years). For Aim II, I found that >80% of GPs reported they would deprescribe ≥ 1 medication(s) in patients aged ≥ 80 years with polypharmacy. There was some variation across countries and GP characteristics with regards to the reported deprescribing decisions. The GPs’ odds of making deprescribing decisions was higher in patients with a higher level of functional dependency in activities of daily living (ADL) (high functional dependency in ADL: odds ratio (OR) = 1.5, 95% CI 1.25-1.80, medium: OR = 1.29, 95% CI 1.09-1.55, reference category: low functional dependency in ADL) and when cardiovascular disease was absent (OR = 3.04, 95% CI 2.58-3.57, reference: history of cardiovascular disease). For Aim III, I found that more than 80% of older multimorbid patients with polypharmacy, who participated in the OPTICA trial, reported being willing to stop ≥ 1 of their medications if their doctor said that this would be possible. The baseline characteristics of GPs participating in the OPTICA trial were similar in terms of sociodemographic characteristics and their work as GPs to those regularly exporting data to the FIRE project database (e.g., age, years of experience as GP, employment status). Patients participating in the OPTICA trial and those from the FIRE database were comparable in terms of age, health services use, and certain clinical characteristics (e.g., systolic blood pressure, body mass index). I also demonstrated that patients recruited based on pre-defined screening lists were similar to those identified by GPs. Finally, we observed an overall good acceptance of the STRIP assistant by general practitioners who used this tool during the OPTICA trial. GPs reported to perceive the STRIP assistant as a useful tool, due to its nature to manage a large amount of data and to generate recommendations. Despite this, some substantial implementation challenges were observed. The qualitative findings showed that the main reasons for the limited implementation of the STRIP assistant are as follows: incomplete data imports, significant time expenditure for preparing the use of the STRIP assistant, technical problems when running the medication review analysis, and occasional lack of quality and inappropriateness of the generated recommendations.
Conclusions
This thesis provides important information for optimizing medication use in older adults with multimorbidity and polypharmacy. First, I found an overall high utilization of PIMs in older adults with multimorbidity and polypharmacy, which is associated with substantial costs. We as researchers should use the information on the factors associated with new PIM prescribing and the information on the most commonly used PIMs when developing interventions targeted at optimizing the medication use in older adults with multimorbidity and polypharmacy that aim at reducing the use of PIMs in this patient group. Second, GPs overall seem to be willing to deprescribe medication in older patients with polypharmacy. However, GPs’ willingness to make deprescribing decisions differed for patients with different levels of functional dependency in activities of daily living and cardiovascular disease. In addition, patients with multimorbidity and polypharmacy also show a high willingness to have medications deprescribed. I conclude that designing deprescribing interventions that build on GPs and patients’ willingness to make deprescribing decisions could be a crucial factor for the implementation and long-term efficacy of such interventions. Finally, I conclude that testing new medication optimization interventions in primary care trials with comparable groups of GPs and older multimorbid patients is possible. However, the implementation of new electronic decision support systems may come with substantial challenges, which have to be addressed to facilitate and enable the future rollout of such tools
Adresses de contact
No full textCécile Bolly, Jean-Marie Degryse, Dominique Pestiaux, Carl Vanwelde, Bernard Vercruysse : CAMG UCL, 5360, Tour Pasteur, avenue E. Mounier, 53, 1200 Bruxelles (Belgique). Tel. +32.2.764.53.44, Fax. +32.2.764.53.27. Jacobijn Gussekloo : Section of Gerontology and Geriatrics, Department of General Internal Medicine, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, Netherlands. Jan De Lepeleire : ACHG Kuleuven, Kapucijnenvoer 33 blok j -bus 7001, B-3000 Leuven. Tel. +32.16.337 468, ..
Optimizing medication use for elderly patients
No full textKwint H-F, Faber A, Gussekloo J, Bouvy ML. Optimizing medication use for elderly patients. Huisarts Wet 2015;58(3):134-8. In conclusion, the studies presented in the thesis show the importance of the different steps of the medication review process when prescribing for elderly patients and the outcomes achieved. Studies of older users of multidose drug dispensing systems provide insight into the quality of medication use in these individuals. Further research is needed, for example, to determine which older patients will benefit the most from medication review or use of multidose drug dispensing systems. The thesis Improving appropriate medication use for older people in primary care investigated how the medication use of elderly patients on polypharmacy in primary care can be optimized, with emphasis on the effects of medication review and multidose dispensing systems. In this article, we present a series of studies from this thesis. We describe the effect of medication review on drug-related problems, disease-specific outcomes, and health-related quality of life. Thereafter we focus on the different steps of the medication review process, such as the medication history and the possible role of explicit STOPP-START criteria in the identification of drug-related problems. We investigated the extent of inappropriate prescribing to older patients receiving their drugs via multidose drug dispensers and compared the self-reported medication adherence and knowledge of these patients with those of patients receiving manually dispensed drugs
Lower blood pressure during antihypertensive treatment is associated with higher all-cause mortality and accelerated cognitive decline in the oldest-old-data from the Leiden 85-plus Study.
No full textBackground
the appropriateness of lowering systolic blood pressure remains controversial in the oldest-old. We tested whether systolic blood pressure is associated with all-cause mortality and change in cognitive function for patients prescribed antihypertensive treatment and those without treatment.
Methods
we studied participants in the population-based Leiden 85-plus cohort study. Baseline systolic blood pressure and use of antihypertensive treatment were predictors; all-cause mortality and change in cognitive function measured using the Mini-Mental State Examination were the outcomes. Grip strength was measured as a proxy for physical frailty. We used Cox proportional hazards and mixed-effects linear regression models to analyse the relationship between systolic blood pressure and both time to death and change in cognitive function. In sensitivity analyses, we excluded deaths within 1 year and restricted analyses to participants without a history of cardiovascular disease.
Results
of 570 participants, 249 (44%) were prescribed antihypertensive therapy. All-cause mortality was higher in participants with lower blood pressure prescribed antihypertensive treatment (HR 1.29 per 10 mmHg lower systolic blood pressure, 95% CI 1.15-1.46, P < 0.001). Participants taking antihypertensives showed an association between accelerated cognitive decline and lower blood pressure (annual mean change -0.35 points per 10 mmHg lower systolic blood pressure, 95% CI -0.60, -0.11, P = 0.004); decline in cognition was more rapid in those with lower hand grip strength. In participants not prescribed antihypertensive treatment, no significant associations were seen between blood pressure and either mortality or cognitive decline.
Conclusions
lower systolic blood pressure in the oldest-old taking antihypertensives was associated with higher mortality and faster decline in cognitive function
Burden of cardiovascular disease across 29 countries and GPs' decision to treat hypertension in oldest-old
No full textObjectives: We previously found large variations in general practitioner (GP) hypertension treatment probability in oldest-old (>80 years) between countries. We wanted to explore whether differences in country-specific cardiovascular disease (CVD) burden and life expectancy could explain the differences. Design: This is a survey study using case-vignettes of oldest-old patients with different comorbidities and blood pressure levels. An ecological multilevel model analysis was performed. Setting: GP respondents from European General Practice Research Network (EGPRN) countries, Brazil and New Zeeland. Subjects: This study included 2543 GPs from 29 countries. Main outcome measures: GP treatment probability to start or not start antihypertensive treatment based on responses to case-vignettes; either low (<50% started treatment) or high (!50% started treatment). CVD burden is defined as ratio of disability-adjusted life years (DALYs) los
Association of low blood pressure and falls: An analysis of data from the Leiden 85-plus Study.
No full textBACKGROUND
Falls and consequent injuries are prevalent in older adults. In this group, half of injury-related hospitalizations are associated with falls and the rate of falls increases with age. The evidence on the role of blood pressure and the use of antihypertensive treatment on the risk of falls remains unclear in oldest-old adults (≥85 years).
OBJECTIVES
To examine the association between systolic blood pressure (SBP) and incident falls with medical consequences in oldest-old adults and to analyse whether this association is modified by the use of antihypertensive treatments or the presence of cardiovascular disease.
METHODS
We analysed data from the Leiden 85-plus Study, a prospective, population-based cohort study with adults aged ≥85 years and a 5-year follow-up. Falls with medical consequences were reported by the treating physician of participants. We assessed the association between time-updated systolic blood pressure and the risk of falling over a follow-up period of five years using generalized linear mixed effects models with a binomial distribution and a logit link function. Subgroup analyses were performed to examine the role of antihypertensive treatment and the difference between participant with and without cardiovascular disease.
RESULTS
We analysed data from 544 oldest-old adults, 242 (44.4%) of which used antihypertensives. In 81 individuals (15%) ≥1 fall(s) were reported during the follow-up period. The odds for a fall decreased by a factor of 0.86 (95% CI 0.80 to 0.93) for each increase in blood pressure by 10 mmHg. This effect was specific to blood pressure values above 130mmHg. We did not find any evidence that the effect would be modified by antihypertensive treatment, but that there was a tendency that it would be weaker in participants with cardiovascular disease (OR 0.81, 95% CI 0.72 to 0.90 per 10mmHg) compared to those without cardiovascular disease (OR 0.94, 95% CI 0.84 to 1.05 per 10mmHg).
CONCLUSION
Our results point towards a possible benefit of higher blood pressure in the oldest-old with respect to falls independent of the use of antihypertensive treatments
- …
