Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions.

Background: Polypharmacy paves the way for non-adherence, adverse drug reactions, negative health outcomes, increased use of healthcare services and rising costs. Since it is most prevalent in the older adults, there is an urgent need for introducing effective strategies to prevent and manage the problem in this age group. Purpose: To perform a scoping review critically analysing the available literature referring to the issue of polypharmacy management in the older adults and provide narrative summary. Data sources: Articles published between January 2010-March 2018 indexed in CINHAL, EMBASE and PubMed addressing polypharmacy management in the older adults. Results: Our search identified 49 papers. Among the identified interventions, the most often recommended ones involved various types of drug reviews based on either implicit or explicit criteria. Implicit criteria-based approaches are used infrequently due to their subjectivity, and limited implementability. Most of the publications advocate the use of explicit criteria, such as e.g. STOPP/START, Beers and Medication Appropriateness Index (MAI). However, their applicability is also limited due to long lists of potentially inappropriate medications covered. To overcome this obstacle, such instruments are often embedded in computerised clinical decision support systems. Conclusion: Multiple approaches towards polypharmacy management are advised in current literature. They vary in terms of their complexity, applicability and usability, and no "gold standard" is identifiable. For practical reasons, explicit criteria-based drug reviews seem to be advisable. Having in mind that in general, polypharmacy management in the older adults is underused, both individual stakeholders, as well as policymakers should strengthen their efforts to promote these activities more strongly.

Medication adherence in the older adults with chronic multimorbidity: a systematic review of qualitative studies on patient's experience.

PURPOSE: Medication non-adherence represents a socially relevant challenge, particularly when interlinked to multiple chronic diseases and polypharmacy. Non-adherence rates affect treatment efficacy and increase health care costs. The aim of the study was to identify factors influencing medication adherence in the older adults through a systematic review of qualitative studies on patients' experience. METHODS: Two electronic databases were searched for qualitative studies on medication adherence in chronic diseases (hypertension, heart disease, COPD, asthma) involving people aged 65 + . The systematic review was performed according to the PRISMA statement guidelines, employing theoretical frameworks of the ABC Taxonomy of patient adherence and Three Factor model of determinants of behaviour. RESULTS: The initial database search identified 1234 records, of which 39 studies were considered eligible. Most of the studies focused on hypertension and were conducted in English-speaking countries. According to the ABC Taxonomy, Persistence and Implementation were the most often considered phases. Considering the Three Factor model, the most often reported themes were Information and Strategies upon being adherent. Stemming from the review findings and the patients' narratives, a new integrated model was proposed. It reports the patient's decisional flowchart describing barriers and facilitators (personal, social and environmental) to adherence. CONCLUSION: Medication adherence is a complex and multifaceted process. The implementation of theoretical frameworks along with a patient-centred perspective may provide clinicians with useful suggestions for clinical practice, enhancing the patient's ability to adhere.

Diffuse gastrointestinal bleeding and BK polyomavirus replication in a pediatric allogeneic haematopoietic stem cell transplant patient.

Patients undergoing haematopoietic stem cell transplantation (HSCT) are at high risk of severe gastrointestinal bleeding caused by infections, graft versus host disease, and disturbances in haemostasis. BK polyomavirus (BKPyV) is known to cause hemorrhagic cystitis, but there is also evidence of BKV shedding in stool and its association with gastrointestinal disease. We report putative association of BKPyV replication with high plasma viral loads in a pediatric HSCT patient developing hemorrhagic cystitis and severe gastrointestinal bleeding necessitating intensive care. The observation was based on chart review and analysis of BKPyV DNA loads in plasma and urine as well as retrospective BKPyV-specific IgM and IgG measurements in weekly samples until three months post-transplant. The gastrointestinal bleeding was observed after a >100-fold increase in the plasma BKPyV loads and the start of hemorrhagic cystitis. The BKPyV-specific antibody response indicated past infection prior to transplantation, but increasing IgG titers were seen following BKPyV replication. The gastrointestinal biopsies were taken at a late stage of the episode and were no longer informative of BK polyomavirus involvement. In conclusion, gastrointestinal complications with bleeding are a significant problem after allogeneic HSCT to which viral infections including BKPyV may contribute.

A case of primary JC polyomavirus infection-associated nephropathy.

A 15-year-old boy with a posterior urethral valve received a deceased donor kidney transplant (KT) in March 2011. Basiliximab induction followed by tacrolimus-based triple medication was used as immunosuppression. Eleven months after KT, the graft function deteriorated and the biopsy demonstrated interstitial nephritis suggestive of acute rejection. BK polyomavirus (BKPyV) surveillance in urine and plasma was negative. The patient received methylprednisolone pulses and anti-thymocyte globulin. Immunohistochemistry was positive for simian virus 40 (SV40) large T-antigen (LTag) in the biopsies, and quantitative polymerase chain reaction for JC polyomavirus (JCPyV) indicated high viral loads in urine and borderline levels in plasma. Immunosuppression was reduced and follow-up biopsies showed tubular atrophy and interstitial fibrosis. Two years after KT, antibody-mediated rejection resulted in graft loss and return to hemodialysis. Retrospective serologic work-up indicated a primary JCPyV infection with seroconversion first for IgM, followed by IgG, but no indication of BKPyV infection. In the SV40 LTag positive biopsies, JCPyV deoxyribonucleic acid (DNA) with archetype noncoding control region was detected, while BKPyV DNA was undetectable. To the best of our knowledge, this is the first reported case of primary JCPyV infection as the cause of PyV-associated nephropathy in KT.

BK polyomavirus-specific cellular immune responses are age-dependent and strongly correlate with phases of virus replication.

BK polyomavirus (BKPyV) infection is widespread and typically asymptomatic during childhood, but may cause nephropathy in kidney transplant recipients. However, there is only limited knowledge on BKPyV-specific immunity in children and adults, and its role in BKPyV-replication and disease posttransplant. We therefore characterized BKPyV-specific immunity from 122 immunocompetent individuals (1-84 years), 38 adult kidney recipients with (n = 14) and without BKPyV-associated complications (n = 24), and 25 hemodialysis (HD) patients. Blood samples were stimulated with overlapping peptides of BKPyV large-T antigen and VP1 followed by flow-cytometric analysis of activated CD4 T cells expressing interferon-γ, IL-2 and tumor necrosis factor-α. Antibody-levels were determined using enzyme-linked immunosorbent assay. Both BKPyV-IgG levels and BKPyV-specific CD4 T cell frequencies were age-dependent (p = 0.0059) with maximum levels between 20 and 30 years (0.042%, interquartile range 0.05%). Transplant recipients showed a significantly higher BKPyV-specific T cell prevalence (57.9%) compared to age-matched controls (21.7%) or HD patients (28%, p = 0.017). Clinically relevant BKPyV-replication was associated with elevated frequencies of BKPyV-specific T cells (p = 0.0002), but decreased percentage of cells expressing multiple cytokines (p = 0.009). In conclusion, BKPyV-specific cellular immunity reflects phases of active BKPyV-replication either after primary infection in childhood or during reactivation after transplantation. Combined analysis of BKPyV-specific T cell functionality and viral loads may improve individual risk assessment.

The DIACOM study (effect of DosIng frequency of oral Antidiabetic agents on the COMpliance and biochemical control of type 2 diabetes).

AIM: Sulphonylureas are widely used in the management of type 2 diabetes. The effectiveness of treatment with oral antidiabetic drugs depends largely on patient compliance. The objective of the DIACOM (effect of DosIng frequency of oral Antidiabetic agents on the COMpliance and biochemical control of type 2 diabetes) study was to compare the compliance of patients treated with once-daily (od) or twice-daily (bid) sulphonylureas. METHODS: One hundred and five patients, previously treated with glibenclamide, were randomized to receive gliclazide in modified-release formulation (MR) once daily or glibenclamide twice daily for 16 weeks, using an electronic monitoring system (MEMS). RESULTS: A significant difference in compliance was observed between the two groups. The overall compliance was 93.5+/-14.0% in the once-daily gliclazide MR group and 87.2+/-21.1% in the twice-daily glibenclamide group (p<0.05), and the correct number of doses was taken on 86.3+/-15.4 and 66.9+/-29.0% of treatment days respectively (p<0.0001). The percentage of missed doses was 9.3+/-12.5% in the once-daily group and 17.5+/-18.0% in the twice-daily group (p<0.01). The percentage of doses taken in the correct time window and correct inter-dose interval was higher in the once-daily group, as was therapeutic coverage. Patients in the gliclazide MR group also achieved significantly better glycaemic control [fasting plasma glucose and glycated haemoglobin (HbA(1c))] than those treated with glibenclamide (p<0.0001). CONCLUSIONS: The study demonstrates that patient compliance with once-daily gliclazide MR is significantly better than with twice-daily glibenclamide. Consistently better efficacy was observed for short-term (fasting glucose) and long-term glycaemic control (HbA(1c)) in the once-daily group. These results demonstrate the possible therapeutic advantages of once-daily agents over twice-daily agents in the treatment of type 2 diabetes.

Non-compliance--some myths, some facts.

Patient non-compliance is a common problem, well known to every practitioner. It is widespread among all patients, regardless of the disease type and intensity. The consequences of non-compliance are very serious, and include inefficacy of applied treatment, deterioration of patient's health state, necessity of additional tests and hospitalisation or even death. Non-compliance also generates increased expenditure within the health care system. Despite all these serious consequences, in many cases doctors do not fully realise how frequently it occurs. Fortunately, there are ways to achieve better compliance. Their implementation may contribute to achieving better results of the therapy and reducing health system expanses at the same time.

[Patient adherence in respiratory tract infections: ceftibuten versus other antibiotics (PARTICULAR study)]. / Przestrzeganie zalecen lekarskich w zakazeniach dróg oddechowych: ceftibuten a inne antybiotyki (badanie PARTICULAR).

The study was conducted to evaluate patient compliance to antibiotic therapy in respiratory tract infections. The main aim of the study was to establish whether dosing frequency (1 vs 2 or 3 times daily) and other factors influence compliance. Patients aged 18 and over attending selected primary health facilities in Lódz region were enrolled. Patients were randomly assigned to receive ceftibuten, 400 mg once daily or other antibiotic on physician's choice with 2 or 3 times daily dosing. On the 5th day during the home visit the questionnaire study was performed and the compliance was measured by a pill count. Four hundred and six patients (205 in ceftibuten and 201 in other antibiotics group, respectively) were fully evaluable. Overall compliance was 76.6% with 97.6% for ceftibuten, 66.0% for antibiotics with b.i.d. dosing and 23.5% for antibiotics with t.i.d. dosing. Using a logistic regression analysis with a stepwise variable selection, dosing frequency was found to be a major variable associated with patient compliance (p = 0.00000, odds ratio 0.09, 95% confidence interval 0.057-0.165). Non-compliance with antibiotics is a common phenomenon in respiratory tract infections therapy. Once-daily antibiotic dosing leads to the best possible compliance in such circumstances. Due to its once-daily dosing and rare side effects, ceftibuten ensures nearly perfect compliance in respiratory tract infections therapy.

[Prader-Willi syndrome in 22-year-old man--case study]. / Przypadek zespolu Pradera-Williego u 22-letniego mezczyzny.

Prader-Willi syndrome is a rare genetic disorder with characteristic neonatal hypotonia, followed by obesity, low height, hypogonadism and mental retardation. In this paper a case of 22-year-old man suffering from Prader-Willi syndrome is described.

[How to enhance patient compliance?]. / Jak polepszyc przestrzeganie zalecen lekarskich?

Patient non-compliance with medication leads to disadvantageous medical consequences and contributes to the rise of expenses of the health care system. Nevertheless, patient non-compliance is an ubiquitous problem. In such circumstances there is a need to apply activities leading to the enhancement of patient compliance. The useful methods are described in this paper. Most of them is widely available and may be applied by physicians, particularly by general practitioners.

[Patient non-compliance as a cause of treatment failure]. / Nieprzestrzeganie zalecen lekarskich przyczyna nieskutecznosci terapii.

Patient non-compliance is a phenomenon which physician meets in his every-day practice. It covers different aspects of patient behaviour, but the most important role plays non-compliance with medication. Medication non-compliance is common among patients, with no respect to kind of disease or its severity. The consequences of non-compliance are serious. The inefficacy of conducted treatment, patient health status deterioration, additional hospitalisations or even deaths are some of them. Another negative influence of patient non-compliance is the increase of health system expenses. Nevertheless, numerous physicians are not fully conscious of this problem and its consequences, although in many instances treatment failure is caused by lack of patient adherence to medication. Many useful methods of compliance improvement are attainable in every physician work. Their broader use may lead to better therapy effectiveness.

[Drug compliance in patients treated with antibiotics in an ambulatory setting for respiratory tract infections]. / Przestrzeganie zalecen lekarskich przez pacjentów leczonych w warunkach ambulatoryjnych antybiotykami z powodu zakazen dróg oddechowych.

Patient non-compliance is a phenomenon which leads to less effective and more expensive therapy, particularly in general practice conditions. One of the most common problem of out-patients care are respiratory infections. The aim of this study was to evaluate the extent of patient non-compliance among out-patients treated with short-time antibiotic for respiratory tract infections and to find factors associated with patient adherence. Two methods of compliance measurement were used: the questionnaire method and pill count. The study group consisted of 154 out-patients with respiratory infections. The pill count method revealed that 46.8% of patients did not take their antibiotics as prescribed, and only 9.7% stated that in inquiry. Patient compliance was associated with such factors as being married, subjective estimation of health state as lower then peers, present chronic diseases, present ischemic heart disease, subjective estimation of disease as "serious", localisation of infection in lower respiratory tract, dosage schedule, the number of drugs taken at examination > 2, the number of drugs doses taken at examination > 6 and the number of drugs taken longer then a week > 2. Age, gender, education and professional activity did not influence the level of compliance. The study points out usefulness of both inquiry and pill count method in revealing patient non-compliance in conditions of general practice.