Potentially inappropriate prescribing among older patients and associated factors: comparison of two versions of STOPP/START criteria

Abstract The study aimed to estimate and compare the prevalence and type of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) between the STOPP/START original (v1) and updated version (v2) among older patients in various settings, as well as associated factors. The study included 440 patients attending a community pharmacy, 200 outpatients and 140 nursing home users. An increase in the prevalence of STOPP v2 (57.9%) compared to v1 (56.2%) was not statistically significant in the total sample and within each setting (p>0.05). A decrease in the prevalence of START v1 (55.8%) to v2 (41.2%) was statistically significant (p<0.001) in the total sample and within each setting (p<0.05). Drug indication (32.9%) and fall-risk medications (32.2%) were most commonly identified for STOPP v2, while cardiovascular system criteria (30.5%) were the most frequently detected for START v2. The number of medications was the strongest predictor for both STOPP v1 and v2, with odds ratio values of 1.35 and 1.34, respectively. Patients' characteristics associated with the occurrence of STOPP and START criteria were identified. According to both STOPP/START versions, the results indicate a substantial rate of potentially inappropriate prescribing among elderly patients. The prevalence of PIMs was slightly higher with the updated version, while the prevalence of PPOs was significantly lower

Associations of Handgrip Strength and Handgrip Strength Asymmetry With Depression in the Elderly in Korea: A Cross-sectional Study.

OBJECTIVES: Recent studies have suggested that assessing handgrip strength (HGS) asymmetry together with HGS may be helpful for evaluating problems in geriatric patients. This study aimed to identify whether HGS asymmetry, weakness, or both were associated with depression in Korean older adults. METHODS: This study included 4274 subjects from the sixth and seventh Korea National Health and Nutrition Examination Survey. Depression was measured using the Patient Health Questionnaire-9. The maximum HGS of the dominant hand was used as a representative value. HGS symmetry was categorized by the ratio of the HGS of the dominant hand to that of non-dominant hand. The odds ratio (OR) for depression was calculated according to the HGS and its symmetry. RESULTS: In total, 240 (12.5%) men and 534 (22.7%) women had depression. HGS or HGS asymmetry showed no statistically significant associations with depression in elderly men. Elevated odds of depression were observed in elderly women with low HGS (OR, 1.93; 95% confidence interval [CI], 1.33 to 2.81) or prominent HGS asymmetry (OR, 1.46; 95% CI, 1.02 to 2.08). There was a positive additive interaction between asymmetric HGS and weakness, as women with low and prominently asymmetric HGS showed higher odds of depression (OR, 3.77; 95% CI, 2.16 to 6.59) than women with high and symmetric HGS. CONCLUSIONS: Depression in elderly Korean women was associated with both low and asymmetric HGS. Our findings support the potential value of HGS asymmetry as an indicator of HGS.

A structure and process evaluation of the Geriatric Emergency Department Intervention model.

BACKGROUND: The positive effect of the Geriatric Emergency Department Intervention (GEDI) model, on the outcomes of frail older adults, is established. This study aimed to describe and evaluate the structures and processes required for the effective delivery of the GEDI model to assist in its potential translation into emergency departments in Australia and overseas. METHODS: This was a descriptive qualitative study. Twenty-four semi-structured interviews were conducted with emergency department staff and GEDI doctors and nurses from a regional hospital in Queensland, Australia. An a priori framework guided interview questions and analysis. RESULTS: Structures required for successful model deployment included having an emergency department physician champion and nurses with gerontology experience, adequate funding, and geriatric specific resources. Processes identified as fundamental to the GEDI model included having a targeted approach to assessment, a patient-centred approach to care, and staff with inter-facility, intra-facility and inter-personal communication skills. CONCLUSIONS: The GEDI model addresses the specific care needs of our aging population. For optimal performance of the model, key structures and processes require identification and acknowledgement. Research involving qualitative methodology is vital for successful translation and integration of emergency department models of care.

Using active information and communication technology for elderly homecare services: A scoping review.

Nowadays, as life expectancy grows, the healthcare industry faces growing challenges related to corresponding increases in chronic diseases. Home care services (HCS) are the solution to this growing problem. It's a general premise that information and communication technology (ICT) can address these health issues and enhances HCS. The scope of our study was the active managerial and supervisory roles of these technologies within HCS. The study aimed to extract, accumulate, and classify the challenges of using active ICT for elderly HCS. We employed the keywords, their synonyms, and their combinations into the searching areas of title, keywords, and abstract. More than 300 resources were collected, and found those 33 articles of those 33 articles were eligible for our study. Later, a team of experts provided their opinions on our gatherings, which were collected individually. According to the expert team's opinions, researchers classified challenges into; technology, human factors, and management.

Construction and validation of an educational gerontotechnology on frailty in elderly people.

OBJECTIVE: to construct and validate an educational gerontechnology on frailty in elderly people. METHOD: a methodological study developed in three stages: educational video construction, validation by expert judges and elderly people. Validation was carried out by 22 judges and 22 elderly people. Educational Content Validation Instrument was used for judges and questions adapted from the Suitability Assessment of Materials questionnaire for elderly people. For validation, agreement criterion greater than 80% was considered, verified using Content Validation Index and binomial test. RESULTS: the video addresses recommendations for elderly people at risk of frailty and health-promoting habits, using cordel literature. An agreement greater than 80% was verified in all items assessed by judges and the target audience. CONCLUSION: the video proved to be valid in terms of content and appearance by judges and elderly people, with the potential to mediate health-promoting educational practices in healthy aging.

A novel predictive tool for prognosis in elderly patients with urinary tract infection: Modified PRACTICE.

PURPOSE: We evaluated whether combining the serum albumin level and the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE) class could be a prognostic predictor in elderly patients with urinary tract infection (UTI). METHODS: We retrospectively included adult patients (age ≥ 65 years) with UTI who were hospitalized in the emergency department (ED) between January 1, 2014 and December 31, 2018. We graded the serum albumin level and classified the PRACTICE score; the modified PRACTICE was defined as the sum of the albumin level grade and the PRACTICE class. We comparatively assessed the predictive value for in-hospital mortality and admission to the intensive care unit (ICU) in survivor and non-survivor groups. RESULTS: In total, the study analysis included 1159 patients, and in-hospital mortality was 3.4% (n = 39). The modified PRACTICE score (4.0 [1.4] vs 6.1 [1.2], p < 0.001) was significantly increased in the non-survivor group. The area under the curve value of factors associated with in-hospital mortality were the Modified Early Warning Score (MEWS) 0.57 (95% CI 0.54-0.60), albumin 0.83 (95% CI 0.81-0.85), PRACTICE 0.71 (95% CI 0.69-0.74), and the modified PRACTICE 0.86 (95% CI 0.84-0.88). Factors associated with ICU admission were MEWS 0.65 (95% CI 0.62-0.68), albumin 0.66 (95% CI 0.64-0.69), PRACTICE 0.66 (95% CI 0.63-0.68), and the modified PRACTICE 0.72 (95% CI 0.69-0.74). CONCLUSION: The modified PRACTICE score can be a useful prognostic predictor in elderly patients with UTI.

Comparison of ibuprofen and piroxicam gel in the treatment of trauma pain: A randomized double-blind trial of geriatric population.

OBJECTIVE: This study aimed to compare the analgesic efficacy of topical ibuprofen and topical piroxicam for acute musculoskeletal injuries. METHODS: In this prospective, randomized, controlled, double-blinded study, geriatric patients were assigned to groups to receive either topical ibuprofen (n = 70) or topical piroxicam (n = 69). The first dose of gel was applied in the emergency department and the remaining doses were self-administered at home by the patients thrice daily for 72 h. For each patient, the initial baseline visual analog scale (VAS) score (V 0) was compared with the VAS scores at the 60 min (V1), 120 min (V2), 24 h (V3) and 72 h (V4) time points. The decreases in VAS scores, clinical effectiveness of the treatments, and incidence of adverse events were evaluated. RESULTS: In the topical ibuprofen group, the VAS scores were significantly lower at each measurement time point compared to baseline (p < .001). The results were as follows: V0 -V: 1.08, 95% CI: 0.56-1.61; V0 -V2: 1.09, 95% CI: 0.49-1.69; V0 -V3: 1.44, 95% CI: 0.81-2.07; V0 -V4: 1.59, 95% CI: 0.91-2.26. The mean percentage decrease in the VAS scores in the topical ibuprofen group was significantly higher than that in the topical piroxicam group (p < .001). The clinical effect of treatment was found to be significantly higher for the ibuprofen gel group (p < .001). There was no substantial difference in treatment-related adverse events between the groups (p > .05). CONCLUSION: Ibuprofen gel, which is a safe treatment option for geriatric patients, is more clinically effective than piroxicam gel. Response to Reviewers.

What Features and Functions Are Desired in Telemedical Services Targeted at Polish Older Adults Delivered by Wearable Medical Devices?-Pre-COVID-19 Flashback.

The emerging wearable medical devices open up new opportunities for the provision of health services and promise to accelerate the development of novel telemedical services. The main objective of this study was to investigate the desirable features and applications of telemedical services for the Polish older adults delivered by wearable medical devices. The questionnaire study was conducted among 146 adult volunteers in two cohorts (C.1: <65 years vs. C.2: ≥65 years). The analysis was based on qualitative research and descriptive statistics. Comparisons were performed by Pearson's chi-squared test. The questionnaire, which was divided into three parts (1-socio-demographic data, needs, and behaviors; 2-health status; 3-telemedicine service awareness and device concept study), consisted of 37 open, semi-open, or closed questions. Two cohorts were analyzed (C.1: n = 77; mean age = 32 vs. C.2: n = 69; mean age = 74). The performed survey showed that the majority of respondents were unaware of the telemedical services (56.8%). A total of 62.3% of C.1 and 34.8% of C.2 declared their understanding of telemedical services. The 10.3% of correct explanations regarding telemedical service were found among all study participants. The most desirable feature was the detection of life-threatening and health-threatening situations (65.2% vs. 66.2%). The findings suggest a lack of awareness of telemedical services and the opportunities offered by wearable telemedical devices.

Agents and robots for collaborating and supporting physicians in healthcare scenarios.

Monitoring patients through robotics telehealth systems is an interesting scenario where patients' conditions, and their environment, are dynamic and unknown variables. We propose to improve telehealth systems' features to include the ability to serve patients with their needs, operating as human caregivers. The objective is to support the independent living of patients at home without losing the opportunity to monitor their health status. Application scenarios are several, and they spread from simple clinical assisting scenarios to an emergency one. For instance, in the case of a nursing home, the system would support in continuously monitoring the elderly patients. In contrast, in the case of an epidemic diffusion, such as COVID-19 pandemic, the system may help in all the early triage phases, significantly reducing the risk of contagion. However, the system has to let medical assistants perform actions remotely such as changing therapies or interacting with patients that need support. The paper proposes and describes a multi-agent architecture for intelligent medical care. We propose to use the beliefs-desires-intentions agent architecture, part of it is devised to be deployed in a robot. The result is an intelligent system that may allow robots the ability to select the most useful plan for unhandled situations and to communicate the choice to the physician for his validation and permission.

Personalizing Sensor-Controlled Digital Gaming to Self-Management Needs of Older Adults with Heart Failure: A Qualitative Study.

Objectives: In older persons with heart failure (HF), an inability to self-manage their disease condition can result in poor health outcomes and quality of life. With the rise in smartphone use and digital game playing among older adults, digital tools such as sensor-controlled digital games (SCDGs) can offer accessible health-promoting tools that are enjoyable and easy to use. However, designing SCDGs that are compelling and aligned with their life values and self-management needs can be challenging. This article describes a qualitative study with older adults with HF who were recruited from a cardiac rehabilitation laboratory in central Texas to identify their perceptions and expectations regarding a SCDG for HF self-management. Materials and Methods: A low-fidelity prototype that demonstrated the features of a SCDG was used to obtain the participants' perceptions about the value of SCDGs for HF self-management with respect to content, customization, flexibility, and usability through qualitative interviews. Results: We interviewed 15 patients with HF (53% women; age range, 53-90 years; 60% white). The concept of SCDGs for HF self-management was highly acceptable (80%). Participants provided suggestions for game characters, progress in the game, and game notifications and incentives. Perceived benefits included helping users track their behaviors and establish routines, become informed on strategies to manage HF, and empower themselves to take charge of their health. Conclusions: The study's findings will guide personalization of SCDG development to motivate patient engagement in HF self-management behaviors.

Psychometric Evaluation of the Chinese Version of the Knowledge and Beliefs About Pain in Elderly Patients With Dementia Questionnaire.

BACKGROUND: The quality of pain management in hospitalized older adult patients with dementia is a crucial issue in healthcare. The knowledge and beliefs of nurses are known to predict their pain management intentions toward this particularly vulnerable patient population. PURPOSE: This study was designed to evaluate the reliability and validity of the Chinese version of the Knowledge and Beliefs About Pain in Elderly Patients With Dementia (KBPED-C) questionnaire using a sample of hospital nurses. METHODS: A cross-sectional study was conducted. The 17-item KBPED-C was distributed between September 2013 and August 2014 to 350 nurses working at a hospital in northern Taiwan. Consistency assessment was conducted using Cronbach's alpha, and construct validity was examined using principal component analysis. Three hundred five nurses (19 men and 286 women) were enrolled using convenience sampling. RESULTS: The mean age of the participants was 30.8 ± 5.8 years. The Cronbach's alpha for internal consistency was .86. The item-total correlation was acceptable. The observed content validity was strong, with a content validity index of .86. Construct validity testing revealed a four-factor structure that accounted for 55.2% of the total variance. The four factors of the KBPED-C questionnaire were "general beliefs about pain and aging," "pain management in the workplace," "knowledge about pain management in older adult patients with dementia," and "beliefs about pain in older people." CONCLUSIONS/IMPLICATIONS FOR PRACTICE: This preliminary validation study showed the high acceptability, reliability, and validity of the KBPED-C for hospital nurses. Future studies may use this questionnaire to explore the beliefs and knowledge of nurses regarding pain in older adult patients with dementia.

Quick-SOFA score ≥ 2 predicts prolonged hospital stay in geriatric patients with influenza infection.

PURPOSE: The quick Sepsis-Related Organ Failure Assessment (qSOFA) score was designed to predict mortality among sepsis patients. However, it has never been used to identify prolonged length of hospital stay (pLOS) in geriatric patients with influenza infection. We conducted this study to clarify this issue. METHODS: We conducted a retrospective case-control study, including geriatric patients (aged ≥ 65 years) with influenza infection visiting the emergency department (ED) of a medical center between January 01, 2010 and December 31, 2015. The included patients were divided into two groups on the basis of their qSOFA score: qSOFA < 2, and qSOFA ≥ 2. Data regarding demographics, vital signs, qSOFA score, underlying diseases, subtypes of influenza, and outcomes were included in the analysis. We investigated the association between qSOFA score ≥ 2 and pLOS (>9 days) via logistic regression. RESULTS: Four hundred and nine geriatric patients were included in this study with a mean age of 79.5 (standard deviation [SD], 8.3) years. The median length of stay (LOS) was 7.0 (interquartile range [IQR], 4-12) days, while the rate of pLOS (> 9 days) was 32%. The median LOS in the qSOFA ≥ 2 group, 11.0 (7-15) days, was longer than the qSOFA < 2 group, 6.0 (4-10) days (p-value <0.01). Logistic regression showed that qSOFA ≥ 2 predicts pLOS with an odds ratio of 3.78 (95% confidence interval, 2.04-6.97). CONCLUSION: qSOFA score ≥ 2 is a prompt and simple tool to predict pLOS in geriatric patients with influenza infection.

Treating hypertension in older adults: Beyond the guidelines.

Hypertension in older adults is extremely common. It constitutes the major modifiable risk factor of cardiovascular disease, premature disability, and death. Despite proven benefits of blood pressure (BP) reduction in older individuals, there is a considerable disagreement between major guidelines surrounding the optimal levels of BP treatment and control to be achieved. Given the high prevalence of older adults with hypertension, nurse practitioners should critically examine the overall benefit of treatment, use of antihypertensive therapies, and BP targets to provide high-quality care to this patient population. The purpose of this article is to outline the evidence surrounding the management of BP in older adults and to offer strategies to reconcile conflicting guideline recommendations.

Construction and validation of a sleep hygiene booklet for the elderly.

OBJECTIVE: to construct and validate an educational booklet for the elderly, with guidelines on sleep hygiene. METHOD: a methodological research with booklet construction; validation by 22 judges and evaluation by 22 elderly people. The content was extracted from the guidelines of the Brazilian Sleep Association and the elderly health manual of the Human Rights Office. The item with Content Validity Index (CVI) greater than 0.8 or whose concordance ratio verified with the Binomial Test was valid and statistically equal to or greater than 80%. RESULTS: the booklet presented 14 guidelines for the elderly about sleep hygiene distributed over 25 pages. All items were evaluated as relevant. The CVI had an average of 0.95 by the judges and 0.95 by the elderly. CONCLUSION: the booklet was constructed and validated as to its content and appearance. It can be used by health professionals in the various services with the elderly.

Gerontotechnology for fall prevention of the elderly with Parkinson.

OBJECTIVE: to develop the gerontological nursing care process among the elderly with Parkinson's disease, aiming at the promotion of health through the creation of gerontotechnologies for fall prevention. METHOD: Convergent Care Research was used as a methodological route. Data were collected from February to October 2017, with the participation of nine elderly people with Parkinson's disease. An educational booklet, a memory game called "não cai istepô", a memory game called "caiu de maduro" were developed through clinical evaluation through scales, recorded semi-structured interview and workshops. RESULTS: the application of gerontotechnology resulted from the elderly in self-care, empowerment and knowledge through play, revealing interest in behavior change, independence and learning, as well as serving as a facilitator of care. CONCLUSION: the gerontotechnologies presented as a playful and innovative instrument for the nursing gerontological care process.

Treatment with Statins in Elderly Patients.

Elderly patients are a special category of patients, due to the physiological changes induced by age, the great number of comorbidities and drug treatment and last, but not least, to the cognitive dysfunction frequently encountered in this population. Cardiovascular disease is the most important cause of morbidity and mortality in elderly individuals worldwide. The rate of cardiovascular events increases after 65 years in men and after 75 years in women. Myocardial infarction and stroke are the leading disorders caused by atherosclerosis, that lead to death or functional incapacity. Elderly people have a greater risk to develop atherosclerotic cardiovascular disease. The incidence and prevalence of atherosclerosis increase with age and the number of cardiovascular events is higher in elderly patients. The most efficient treatment against atherosclerosis is the treatment with statins, that has been shown to decrease the risk both of stroke and coronary artery disease in all age groups. The advantages of the treatment become evident after at least one year of treatment. Primary prevention is the most important way of preventing cardiovascular disease in elderly individuals, by promoting a healthy lifestyle and reducing the risk factors. Secondary prevention after a stroke or myocardial infarction includes mandatory a statin, to diminish the risk of a recurrent cardiovascular event. The possible side effects of statin therapy are diabetes mellitus, myopathy, and rhabdomyolysis, hepatotoxicity. The side effects of the treatment are more likely to occur in elderly patients, due to their multiple associated comorbidities and drugs that may interact with statins. In elderly people, the benefits and disadvantages of the treatment with statins should be put in balance, especially in those receiving high doses of statins.

The Automatic Assessment of Strength and Mobility in Older Adults: A Test-Retest Reliability Study.

Background: Simple field tests such as the Timed Up and Go test (TUG) and 30 s Chair Stand test are commonly used to evaluate physical function in the elderly, providing crude outcome measures. Using an automatic chronometer, it is possible to obtain additional kinematic parameters that may lead to obtaining extra information and drawing further conclusions. However, there is a lack of studies that evaluate the test-retest reliability of these parameters, which may help to judge and interpret changes caused by an intervention or differences between populations. Thus, the aim of this study was to evaluate the test-retest reliability of the Timed Up and Go test (TUG) and 30 s Chair Stand test in healthy older adults. Methods: A total of 99 healthy older adults participated in this cross-sectional study. The TUG and the 30 s Chair Stand test were performed five times and twice, respectively, using an automatic chronometer. The sit-to-stand-to-sit cycle from the 30 s Chair Stand test was divided into two phases. Results: Overall, reliability for the 30 s Chair Stand test was good for almost each variable (intraclass correlation coefficient (ICC) >0.70). Furthermore, the use of an automatic chronometer improved the reliability for the TUG (ICC >0.86 for a manual chronometer and ICC >0.88 for an automatic chronometer). Conclusions: The TUG and the 30 s Chair Stand test are reliable in older adults. The use of an automatic chronometer in the TUG is strongly recommended as it increased the reliability of the test. This device enables researchers to obtain relevant and reliable data from the 30 s Chair Stand test, such as the duration of the sit-to-stand-to-sit cycles and phases.

Implementing Evidence-Based Guidelines for Falls Prevention: Observations of Nursing Activities During the Care of Older People With Cognitive Impairment.

BACKGROUND: Evidence-based guidelines assist clinicians in practice, but how the guidelines are implemented is less established. AIM: To describe the nurses' implementation of activities recommended in evidence-based guidelines for falls prevention and care of older people with cognitive impairment. METHODS: Structured observation with a categorical checklist was used. Nursing personnel were recruited from one subacute and two acute wards in two hospitals in one tertiary-level health service in south-eastern Queensland, Australia. The data collection instrument identified 31 activities drawn directly from the evidence-based guidelines, which were categorized into six domains of nursing practice: clinical care, comfort, elimination, mobility, nutrition and hydration, and social engagement. Four-hour observation periods, timed to occur across the morning and evening shifts, were conducted over 2 months. RESULTS: Nineteen registered nurses, six enrolled nurses, and 16 assistants in nursing (N = 41) were observed for 155 hr of observation. There was variability in adherence with specific activities, ranging from 21% to 100% adherence. Three categories with the highest adherence were nutrition and hydration, mobilization safety, and social engagement. The clinical care, comfort, and elimination categories had lower adherence, with lowest adherence in activities of education provision about falls risk, pain assessment, using a clock or calendar to reorient to time and place, and bowel care. LINKING EVIDENCE TO ACTION: Nursing care is delivered within an interdisciplinary team. Therefore, responsibility for the everyday fundamental care activities known to prevent falls in older people with cognitive impairment requires localized negotiation. A practical guide for preventing in-hospital falls in older people with cognitive impairment addressing the interdisciplinary context of practice is required. Interdisciplinary teams should develop strategies to enhance the implementation of pain assessment and prevention of constipation in the context of regularly implemented hydration, nutrition, and mobilization care strategies.