Deprescribing in older adults with polypharmacy.

Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.

Feasibility of frequent patient-reported outcome surveillance in patients undergoing hematopoietic cell transplantation.

Patient-reported outcomes (PROs), including symptoms and health-related quality of life (HRQOL), provide a patient-centered description of hematopoietic cell transplantation (HCT)-related toxicity. These data characterize the patient experience after HCT and may have prognostic usefulness for long-term outcomes after HCT. We conducted a study of 32 patients after HCT (10 autologous HCT recipients, 11 full-intensity conditioning allogeneic HCT recipients, and 11 reduced-intensity conditioning allogeneic HCT recipients) to determine the feasibility of weekly electronic PRO collection from HCT until day (D) +100. We used questions from the PRO version of the Common Terminology Criteria for Adverse Events to capture symptoms, and the Patient-Reported Outcomes Measurement Information System Global Health scale to measure physical and mental HRQOL. The vast majority (94%) of patients used the electronic PRO system, with only 6% opting for paper-and-pencil only. The median weekly percentage of participants who completed the surveys was 100% in all cohorts through hospital discharge, and remained 100% for the autologous HCT and reduced-intensity allogeneic HCT cohorts through D+100. Patients were satisfied with the electronic system, giving high marks for readability, comfort, and questionnaire length. Symptom severity varied by absolute level and type of symptom across the 3 cohorts, with the full-intensity allogeneic HCT cohort exhibiting the greatest median overall symptom severity, peaking at D+7. Median physical health HRQOL scores decreased with time in the 3 cohorts, and HRQOL was generally correlated with overall symptom severity. Our results demonstrate the feasibility of frequent electronic PROs in the early post-HCT period. Future studies in larger populations to explore predictive models using frequent PRO data for outcomes, including long-term HRQOL and survival, are warranted.

Geriatric Care in the Community Setting: Comprehensive Geriatric Assessment.

A comprehensive geriatric assessment (CGA) is a systematic, multidisciplinary evaluation of older adult patients with the goal of identifying and managing geriatric conditions and syndromes. It focuses on various medical, social, and environmental issues. A CGA ideally is performed as an in-person outpatient visit, either in a clinical setting or the home of the patient. The physician, family members and/or caregivers, and a social worker are key contributors. Involvement of family members or caregivers particularly is important if cognitive issues or mood disorders are of concern. Physical therapists, occupational therapists, nurses, speech-language pathologists, dietitians, audiologists, and pharmacists also can provide additional expertise. Many questionnaires and assessment tools are available to simplify data gathering, including assessments of functional status, frailty, mobility, fall risk, nutritional status, polypharmacy, and cognition. These assessments can be completed by patients, family members, or caregivers with assistance from members of the medical team. CGAs should be guided by the Geriatric 5M's framework: mind, mobility, medications, multicomplexity, and matters most. A systematic review of these elements can help identify areas of need and requirements for support for older adult patients.