Serotonin syndrome: A pharmacovigilance comparative study of drugs affecting serotonin levels.

BACKGROUND: Serotonin syndrome is a rare and potentially fatal adverse drug reaction caused by serotonergic drugs and is due to an increase in serotonin concentration or activation of the 5-HT receptor in the central nervous system. We analysed adverse events in the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) data set to investigate the main drug classes related to reports of serotonin syndrome and the reporting risk in relation to age and sex. METHODS: We analysed data from the FAERS database to evaluate the main drug classes related to reports of the serotonin syndrome, and the reporting risk in relation to age and sex. RESULTS: We found 8,997 cases of serotonin syndrome; selective serotonin reuptake inhibitors (SSRIs) was the class of drugs with most reports, followed by opioids and other antidepressants. The highest Reporting Odds Ratios (ROR) for drug classes was for monoamine oxidase (MAO) inhibitors (45.99, 95% confidence interval (CI): 41.21-51.33) and SSRIs (32.66, 95% CI: 31.33-34.04), while the ten active substances with the highest ROR were moclobemide, isocarboxazid, oxitriptane, tranylcypromine, melitracen, phenelzine, linezolid, amoxapine, reboxetine and tryptophan; with values of ROR ranging from 44.19 (95% CI: 25.38-76.94) of tryptophan to 388.36 (95% CI: 314.58-479.46) of moclobemide. The ROR for the most commonly involved drugs was higher in the group of older adults (65 > years old), and higher in males. CONCLUSION: Prescribers need to be vigilant about drugs that can raise serotonin concentration or influence serotonergic neurotransmission, also when using drugs with less well-known risk for serotonin syndrome, like linezolid and triptans.

Prevalence of Delirium in End-of-Life Palliative Care Patients: An Observational Study.

OBJECTIVES: The aim of this study was to assess the prevalence of delirium, using the Assessment Test for Delirium and Cognitive Impairment (4AT) in end-of-life palliative care patients. SUBJECTS AND METHODS: This retrospective cross-sectional study was conducted on end-of-life patients in a hospice or at home. All patients were evaluated with the 4AT for the presence of delirium. RESULTS: Of the 461 patients analyzed, 76 (16.5%) were inpatients and 83.5% (385) outpatients. The median age was 79.5 (72-86) years, and 51.0% were female. According to the 4AT score, 126 patients (27.3%) had delirium (A4T ≥4) at admission, 28 (36.8%) were inpatients, and 98 (25.5%) outpatients. Around 33.8% of the cancer inpatients had delirium, while 20.6% of the cancer outpatients had delirium. The prevalence of delirium varied according to the setting, clinical condition, and life expectancy. In addition, 55.0% (11) actively dying inpatients, within 3 days, had delirium, and 56.7% (17) outpatients had delirium; while among those with life expectancy longer than 4 days, 30.4% (17) inpatients and 22.8% (81) outpatients were with delirium. CONCLUSIONS: Our study confirms that delirium is common in cancer and noncancer palliative care patients. Further research on delirium in end-of-life palliative care patients should consider the complexity of palliative care of this population as well as of the characteristics of the settings.

Factors Associated with a High-Risk Profile for Developing Pressure Injuries in Long-Term Residents of Nursing Homes.

OBJECTIVES: Pressure injuries are a health problem of special concern for older adults, and different scales are used to assess the risk of developing these ulcers. We assessed the prevalence of residents at high risk of pressure injuries using a Norton scale and examined its relationships with the most important risk factors in a large sample of Italian nursing homes (NHs). METHOD: This was a cross-sectional cohort study in a sample of Italian long-term care NHs with data collected between 2018 and 2020. RESULTS: We recruited 2,604 NH residents; 1,252 had Norton scale scores, 41 (3.3%) had a diagnosis of pressure injuries, 571 (45.6%) had a Norton score ≤9, and 453 (36.2%) had a score between 10 and 14. The univariate model showed a relationship between female sex, age, dementia, and cerebrovascular disease with a Norton scale score ≤9. The significant associations were confirmed in the multivariate model with stepwise selection. CONCLUSION: The prevalence of NH residents at high risk of pressure injuries was very high using the Norton scale, but the percentage of residents who develop these ulcers is lower. Female NH residents with advanced age, dementia, and a history of cerebrovascular disease should be carefully monitored.

Anticholinergic load and delirium in end-of-life patients.

BACKGROUND: Delirium is a neuropsychiatric syndrome associated with negative outcomes, including worsening of cognitive and functional status and an increased burden on patients and caregivers. Medications with anticholinergic effect have been associated with delirium symptoms, but the relationship is still debated. OBJECTIVE: To assess the relation between delirium and anticholinergic load according to the hypothesis that the cumulative anticholinergic burden increases the risk of delirium. METHODS: This retrospective cross-sectional study was conducted in a sample of end-of-life patients in a hospice or living at home between February and August 2019. Delirium was diagnosed on admission using the 4 'A's Test (4AT) and each patient's anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale. RESULTS: Of the 461 eligible for analysis, 124 (26.9%) had delirium. Anticholinergic medications were associated with an increased risk of delirium in univariate (OR (95% CI) 1.26 (1.16-1.38), p < 0.0001) and multivariate models adjusted for age, sex, dementia, tumors, Karnofsky Performance Status (KPS) score, days of palliative assistance, and setting (OR (95% CI) 1.16 (1.05-1.28), p < 0.0001). Patients with delirium had a greater anticholinergic burden than those without, with a dose-effect relationship between total ACB score and delirium. Patients who scored 4 or more had 2 or 3 times the risk of delirium than those not taking anticholinergic drugs. The dose-response relationship was maintained in the multivariate model. CONCLUSIONS: Anticholinergic drugs may influence the development of delirium due to the cumulative effect of multiple medications with modest antimuscarinic activity.

Use of preventive drugs during the last year of life in older adults with cancer or chronic progressive diseases.

PURPOSE: To evaluate the prescription of preventive medications with questionable usefulness in community dwelling elderly adults with cancer or chronic progressive diseases during the last year of life. METHODS: Through the utilization of the healthcare databases of the Lombardy region, Italy, we identified two retrospective cohorts of patients aged 65 years or more, who died in 2018 and had a diagnosis of either a solid cancer (N = 19 367) or a chronic progressive disease (N = 27 819). We estimated prescription of eight major classes of preventive drugs 1 year and 1 month before death; continuation or initiation of preventive drug use during the last month of life was also investigated. RESULTS: Over the last year of life, in both oncologic and non-oncologic patients, we observed a modest decrease in the prescription of blood glucose-lowering drugs, anti-hypertensives, lipid-modifying agents, and bisphosphonates, and a slight increase in the prescription of vitamins, minerals, antianemic drugs, and antithrombotic agents (among oncologic patients only). One month before death, the prescription of preventive drugs was still common, particularly for anti-hypertensives, antithrombotics, and antianemics, with more than 60% of patients continuing to be prescribed most preventive drugs and an over 10% starting a therapy with an antithrombotic, an antianemic, or a vitamin or mineral supplement. CONCLUSION: These findings support the need for an appropriate drug review and improvement in the quality of drug prescription for vulnerable populations at the end-of-life.

Inappropriate prescribing in intermediate care facilities.

Inappropriate prescribing for older people is a global healthcare problem. This study aimed to determine the prevalence of older patients receiving potentially inappropriate medications (PIMs) at admission and discharge at the intermediate care facility of ASP Pio Albergo Trivulzio. We consecutively enrolled 100 patients aged ≥ 65 from December 2017 to May 2018 and evaluated PIMs with the 2015 version of the Beers criteria. We found a significant reduction in the prescription of drugs to avoid and proton pump inhibitors (PPIs), while patients with at least one psychotropic drug to avoid or to use with caution significantly increased. The inappropriate prescription of PPIs was mainly associated with the use of heparin. Optimizing PPI and psychotropic drug prescriptions should be considered for deprescribing inappropriate polypharmacy in intermediate care facilities.

Comparison between drug therapy-based comorbidity indices and the Charlson Comorbidity Index for the detection of severe multimorbidity in older subjects.

BACKGROUND: To know burden disease of a patient is a key point for clinical practice and research, especially in the elderly. Charlson's Comorbidity Index (CCI) is the most widely used rating system, but when diagnoses are not available therapy-based comorbidity indices (TBCI) are an alternative. However, their performance is debated. This study compares the relations between Drug Derived Complexity Index (DDCI), Medicines Comorbidity Index (MCI), Chronic Disease Score (CDS), and severe multimorbidity, according to the CCI classification, in the elderly. METHODS: Logistic regression and Receiver Operating Characteristic (ROC) analysis were conducted on two samples from Italy: 2579 nursing home residents (Korian sample) and 7505 older adults admitted acutely to geriatric or internal medicine wards (REPOSI sample). RESULTS: The proportion of subjects with severe comorbidity rose with TBCI score increment, but the Area Under the Curve (AUC) for the CDS (Korian: 0.70, REPOSI: 0.79) and MCI (Korian: 0.69, REPOSI: 0.81) were definitely better than the DDCI (Korian: 0.66, REPOSI: 0.74). All TBCIs showed low Positive Predictive Values (maximum: 0.066 in REPOSI and 0.317 in Korian) for the detection of severe multimorbidity. CONCLUSION: CDS and MCI were better predictors of severe multimorbidity in older adults than DDCI, according to the CCI classification. A high CCI score was related to a high TBCI. However, the opposite is not necessarily true probably because of non-evidence-based prescriptions or physicians' prescribing attitudes. TBCIs did not appear selective for detecting of severe multimorbidity, though they could be used as a measure of disease burden, in the absence of other solutions.

Drug prescriptions in nursing home residents: an Italian multicenter observational study.

PURPOSE: Pharmacoepidemiological studies aimed to distinguish drug use in nursing home (NH) residents with and without dementia could be useful to target specific interventions to improve prescribing. This multicenter retrospective study aimed (i) to describe drug therapy in a large sample of NH residents according to the diagnosis of dementia, and (ii) to record the most frequent potentially severe drug-drug interactions. METHODS: This study was conducted in a sample of Italian long-term care NHs. Drug prescription information, diseases, and socio-demographic characteristics of NH residents were collected at three different times during 2018. RESULTS: The mean number of drugs was significantly higher in NH residents without dementia than in those with (p = 0.05). Antipsychotics, laxatives, benzodiazepines, antiplatelets, and proton pump inhibitors (PPIs) were most commonly prescribed in patients with dementia, and PPIs, benzodiazepines, and laxatives in those without. The prevalence of patients with potentially severe drug-drug interactions was higher among those without dementia, 1216 (64.7%) and 518 (74.2%, p < 0.0001). There were significant differences between the mean numbers of drugs prescribed in individual NH after adjusting the analysis for age, sex, and mean Charlson index, the estimated mean number of drugs prescribed (± standard error) ranging from 5.1 (± 0.3) to 9.3 (± 0.3) in patients with dementia (p < 0.0001) and from 6.0 (± 0.7) to 10.9 (± 0.50) in those without dementia (p < 0.0001). Chronic use of psychotropic drugs was common in NH residents with and without dementia. CONCLUSIONS: The wide variability between NHs in drug prescriptions and potentially inappropriate prescribing suggests the need to recommend a standardized approach to medication review of psychotropic drugs, antiulcer, laxatives, and antiplatelets in this complex and vulnerable population.

Relation between anticholinergic burden and cognitive impairment: Results from the Monzino 80-plus population-based study.

PURPOSE: We examined data collected in the Monzino 80-plus study to assess the relations between cognitive performance and ACB scores according to the hypothesis that a higher anticholinergic burden is associated with reduced cognitive performance. METHODS: The Monzino 80-plus is an ongoing, prospective, door-to-door population-based study started in 2002 among all residents 80 years or older in eight municipalities of Varese province, Italy. To establish the relation between cognitive impairment and the anticholinergic drug burden we recorded the ACB score for each patient at baseline. The relations between ACB score and dementia or MMSE scores were also examined after exclusion of patients taking any antipsychotic. RESULTS: A sample of 2140 elderly people was eligible for analysis. A significant dose-effect relationship was observed between total ACB score and diagnosis of dementia in univariate and multivariate models. Patients in ACB class ≥4 had about 4.5 times the risk of diagnosis of dementia. A relation was also found between higher ACB scores and lower MMSE scores; patients who scored 4 or more had a mean of 6.4 points lower than those not taking anticholinergic drugs. The dose-effect relationship between ACB score and diagnosis of dementia was not maintained after exclusion of patients using antipsychotics, while the association between higher ACB scores and lower MMSE scores was still present, with patients in ACB class ≥4 having a mean score about 4.4 lower. CONCLUSIONS: There are clear relations between anticholinergic load and reduced cognitive performance, while the association with dementia remains uncertain. For primary care and geriatric clinicians, an ACB score ≥ 4 can be considered the cut-off to identify high-risk populations who may benefit from the evaluation of anticholinergic burden with the ACB scale.

Overuse of proton pump inhibitors in nursing homes: An Italian multicenter observational study.

PURPOSE: To examine the prevalence of residents receiving proton pump inhibitors (PPIs) for evidence-based indications in a large sample of Italian nursing homes (NHs) and to assess the predictors of potentially inappropriate prescriptions. METHODS: This study was conducted in a sample of Italian long-term care NHs. Information on drug prescription, diseases, and socio-demographic characteristics of NH residents was collected three times during 2018. Appropriate use of PPI was defined in accordance with the strongest evidence-based indications and the Italian criteria for PPI prescription. RESULTS: Among the 2579 patients recruited from 27 long-term care NHs, 1177 (45.6%) were receiving PPIs; 597 (50.7%) were taking them for evidence-based indications. Corticosteroids, anticoagulants, and mean number of drugs were the most important predictors of inappropriate PPIs prescriptions. NH residents receiving ≥13 drugs had about 10 times the risk of receiving a PPI than those taking 0 to 4 drugs. Similarly, residents with more comorbidity had about 2.5 times the risk of receiving a PPI than those in better health. The prevalence of residents inappropriately treated with PPI in individual NHs varied widely, ranging from 22% to 63%. CONCLUSIONS: Number of drugs, comorbidity, corticosteroids, and anticoagulants are the most important predictors of the inappropriate use of PPI in NHs. The wide variability between NHs in the appropriate use of PPIs suggests the need for thorough drug review in this fragile and vulnerable population. Prescribing patterns linked to evidence-based guidelines and national recommendations are essential for rational, cost-effective use of PPIs.

Need for Deprescribing in Hospital Elderly Patients Discharged with a Limited Life Expectancy: The REPOSI Study.

OBJECTIVE: Older people approaching the end of life are at a high risk for adverse drug reactions. Approaching the end of life should change the therapeutic aims, triggering a reduction in the number of drugs.The main aim of this study is to describe the preventive and symptomatic drug treatments prescribed to patients discharged with a limited life expectancy from internal medicine and geriatric wards. The secondary aim was to describe the potentially severe drug-drug interactions (DDI). MATERIALS AND METHODS: We analyzed Registry of Polytherapies Societa Italiana di Medicina Interna (REPOSI), a network of internal medicine and geriatric wards, to describe the drug therapy of patients discharged with a limited life expectancy. RESULTS: The study sample comprised 55 patients discharged with a limited life expectancy. Patients with at least 1 preventive medication that could be considered for deprescription at the end of life were significantly fewer from admission to discharge (n = 30; 54.5% vs. n = 21; 38.2%; p = 0.02). Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, lipid-lowering drugs, and clonidine were the most frequent potentially avoidable medications prescribed at discharge, followed by xanthine oxidase inhibitors and drugs to prevent fractures. Thirty-seven (67.3%) patients were also exposed to at least 1 potentially severe DDI at discharge. CONCLUSION: Hospital discharge is associated with a small reduction in the use of commonly prescribed preventive medications in patients discharged with a limited life expectancy. Cardiovascular drugs are the most frequent potentially avoidable preventive medications. A consensus framework or shared criteria for potentially inappropriate medication in elderly patients with limited life expectancy could be useful to further improve drug prescription.

Appropriateness of antiplatelet therapy for primary and secondary cardio- and cerebrovascular prevention in acutely hospitalized older people.

AIMS: Antiplatelet therapy is recommended for the secondary prevention of cardio- and cerebrovascular disease, but for primary prevention it is advised only in patients at very high risk. With this background, this study aims to assess the appropriateness of antiplatelet therapy in acutely hospitalized older people according to their risk profile. METHODS: Data were obtained from the REPOSI register held in Italian and Spanish internal medicine and geriatric wards in 2012 and 2014. Hospitalized patients aged ≥65 assessable at discharge were selected. Appropriateness of the antiplatelet therapy was evaluated according to their primary or secondary cardiovascular prevention profiles. RESULTS: Of 2535 enrolled patients, 2199 were assessable at discharge. Overall 959 (43.6%, 95% CI 41.5-45.7) were prescribed an antiplatelet drug, aspirin being the most frequently chosen. Among patients prescribed for primary prevention, just over half were inappropriately prescribed (52.1%), being mainly overprescribed (155/209 patients, 74.2%). On the other hand, there was also a high rate of inappropriate underprescription in the context of secondary prevention (222/726 patients, 30.6%, 95% CI 27.3-34.0%). CONCLUSIONS: This study carried out in acutely hospitalized older people shows a high degree of inappropriate prescription among patients prescribed with antiplatelets for primary prevention, mainly due to overprescription. Further, a large proportion of patients who had had overt cardio- or cerebrovascular disease were underprescribed, in spite of the established benefits of antiplatelet drugs in the context of secondary prevention.

Antipsychotic prescription and mortality in hospitalized older persons.

BACKGROUND: Recent scientific reports have shown that older persons treated with antipsychotics for dementia-related behavioural symptoms have increased mortality. However, the impact of these drugs prescribed during hospitalization has rarely been assessed. We aimed to investigate whether antipsychotics are associated with an increased risk of mortality during hospitalization and at 3-month follow-up in elderly inpatients. METHODS: We analyzed data gathered during two waves (2010 and 2012) by the REPOSI (Registro Politerapie Società Italiana Medicina Interna). All new prescriptions of antipsychotic drugs during hospitalization, whether maintained or discontinued at discharge, were collected, and logistic regression models were used to analyze their association with in-hospital and 3-month mortality. Covariates were age, sex, the Short Blessed Test (SBT) score, and the Cumulative Illness Rating Scale. RESULTS: Among 2703 patients included in the study, 135 (5%) received new prescriptions for antipsychotic drugs. The most frequently prescribed antipsychotic during hospitalization and eventually maintained at discharge was haloperidol (38% and 36% of cases, respectively). Patients newly prescribed with antipsychotics were older and had a higher Cumulative Illness Rating Scale comorbidity index both at admission and at discharge compared to those who did not receive a prescription. Of those prescribed antipsychotics, 71% had an SBT score ≥10 (indicative of dementia), 12% had an SBT score of 5-9 (indicative of questionable dementia); and 17% had an SBT score <5 (indicative of normal cognition). In-hospital mortality was slightly higher in patients prescribed antipsychotic drugs (14.3% vs 9.4%; P = 0.109), but in multivariate analysis only male sex, older age, and higher SBT scores were significantly related to mortality during hospitalization. At 3-month follow-up, only male sex, older age, and higher SBT scores were associated with mortality. CONCLUSION: We found that the prescription of antipsychotic drugs during hospitalization was not associated with in-hospital or follow-up mortality. Short-term antipsychotic prescriptions (for acutely ill patients) may have a different effect than long-term, repeated prescriptions.

E-learning in order to improve drug prescription for hospitalized older patients: a cluster-randomized controlled study.

AIMS: The aim of the study was to evaluate the effect of an e-learning educational program meant to foster the quality of drug prescription in hospitalized elderly patients. METHODS: Twenty geriatric and internal medicine wards were randomized to intervention (e-learning educational program) or control (basic geriatric pharmacology notions). Logistic regression analysis was used in order to assess the effect of the intervention on the use of potentially inappropriate medication (PIM, primary outcome) at hospital discharge. Secondary outcomes were a reduced prevalence of at least one potential drug-drug interaction (DDI) and potentially severe DDI at discharge. Mortality rate and incidence of re-hospitalizations were other secondary outcomes assessed at the 12-month follow-up. RESULTS: A total of 697 patients (347 in the intervention and 350 in the control arms) were enrolled. No difference in the prevalence of PIM at discharge was found between arms (OR 1.29 95%CI 0.87-1.91). We also found no decrease in the prevalence of DDI (OR 0.67 95%CI 0.34-1.28) and potentially severe DDI (OR 0.86 95%CI 0.63-1.15) at discharge, nor in mortality rates and incidence of re-hospitalization at 12-month follow-up. CONCLUSIONS: This e-learning educational program had no clear effect on the quality of drug prescription and clinical outcomes in hospitalized elderly patients. Given the high prevalence of PIMs and potential DDIs recorded in the frame of this study, other approaches should be developed in order to improve the quality of drug prescription in this population.

Changes in clinical outcomes for community-dwelling older people exposed to incident chronic polypharmacy: a comparison between 2001 and 2009.

PURPOSE: The purpose of this study is to explore the effect of incident chronic polypharmacy on 1-year hospitalization, institutionalization, and mortality among older people and to evaluate whether or not the effect differed according to index year (2001 or 2009), sex, and age. METHODS: Data were obtained from the administrative database of the Lombardy region (Northern Italy). We compared community-dwelling elderly people with an incident exposure to chronic polypharmacy (five or more drugs during 1 month for at least 6 months in 1 year) in either index year (2001 and 2009) with not exposed elderly people in the same years. Multivariable logistic (institutionalization) and Cox (hospitalization and death) were performed including year, sex, age classes, and number of drugs as covariates and their respective interaction terms by chronic polypharmacy. RESULTS: We analyzed 1,800,257 elderly subjects in 2001 and 1,567,575 in 2009, with a prevalence of chronic polypharmacy of 1.46% and 2.86%, respectively. Overall, 1-year hospitalization, institutionalization, and mortality rates were lower in 2009 than in 2001. Chronic polypharmacy was significantly associated with the outcomes in multivariable analyses: hazard or odds ratios 1.16 (95% confidence interval 1.14-1.17) for hospitalization, 1.21 (1.12-1.30) for institutionalization, and 1.11 (1.08-1.14) for death. There was no consistent effect modification by index year or sex, whereas chronic polypharmacy was no longer a risk factor for adverse outcomes among those older than 85 years (p < 0.0001 for interaction). CONCLUSIONS: Incident chronic polypharmacy remained an independent predictor of adverse outcomes among community-dwelling elderly people, despite a reduction over time of 1-year hospitalization, institutionalization, and mortality rates.

Potentially Serious Drug-Drug Interactions in Older Patients Hospitalized for Acute Ischemic and Hemorrhagic Stroke.

BACKGROUND: Polypharmacy is very common in older persons and it is associated with inappropriate prescribing and potential drug-drug interactions (DDIs). Aims of this study were to identify prevalence of DDIs in older persons with acute stroke and to evaluate the association between stroke and DDIs. METHODS: One hundred forty-six patients admitted with diagnosis of acute stroke were enrolled. The therapeutic regimen of patients was analyzed at admission to identify the number of DDIs, prevalence and sorts of serious DDIs according to subtype of acute stroke (ischemic or hemorrhagic) and to its recurrence. RESULTS: Five hundred eighty-two DDIs were identified: 18 mild, 415 moderate and 149 serious. Sixty-one percent of patients were exposed to at least one serious DDI. A higher percentage of patients were exposed to at least one serious DDI among those with a recurring ischemic event compared to those with a first event (74 vs. 50%; p < 0.01, respectively). Serious DDIs potentially associated with an increased risk of a cerebral event were identified in 19 (17%) patients with ischemic stroke, and in 7 (19%) patients with hemorrhagic stroke. CONCLUSIONS: The prevalence of serious DDIs was high in aging patients with acute stroke but different according to subtype and recurrence of the cerebrovascular event.

Prevalence of dementia in the oldest old: the Monzino 80-plus population based study.

BACKGROUND: Epidemiological studies commonly include too few of the oldest old to provide accurate prevalence rates of dementia in older age groups. Estimates of the number of those affected, necessary for healthcare planning, are thus flawed. The objective is to estimate the prevalence of dementia and levels of dementia severity in a very large population of oldest old and to investigate the relation between age and dementia prevalence in the extreme ages. METHODS: The Monzino 80-plus is a population-based study among residents 80 years or older in Varese province, Italy. Dementia cases were identified using a one-phase design. The survey was conducted in the participant's place of residence, whether home or institution. Both participants and informants were interviewed. Information was available for 2504 of the 2813 residents (89%). RESULTS: In all, 894 individuals (714 women and 180 men) met the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria for dementia, for a standardized prevalence of 25.3% (95% confidence interval [CI]: 23.4, 27.2%), 28.5% (95% CI: 26.2, 30.9) in women and 18.6% (95% CI: 15.2, 21.9) in men. Age-specific prevalence estimates of dementia increased with age from 15.7% at age 80 to 84 years to 65.9% at age 100 years and higher. For women, prevalence continued to rise after age 100 years, from 64.8% at age 100 to 101 years to 76.1% at age 102 to 107 years. After age 85 years prevalence rates tended to rise linearly, on average 2.6% per year in women and 1.8% in men. About 80% of the cases were moderate or severe. The frequency of mild dementia decreased and that of severe dementia increased with age. CONCLUSION: One-quarter of 80-plus year olds are affected by dementia, mostly moderate or severe. Prevalence rates of dementia do not level off, but continue to rise gradually even in the extreme ages.

Changes in drug prescribing to Italian community-dwelling elderly people: the EPIFARM-Elderly Project 2000-2010.

PURPOSE: To investigate the changes in the last decade (2000-2010) in drug prescribing among community-dwelling elderly people aged 65-94 years, in relation to age and sex. METHODS: We analyzed the data of nearly two million subjects ranging in age from 65 to 94 years recorded in the Drug Administrative Database of the Lombardy Region (Italy) from 2000 to 2010. Associations between drug use (at least one drug, one chronic drug, polypharmacy or chronic polypharmacy) and age, sex, and year of prescription were analyzed by logistic regression analysis. We also analyzed differences in changes linked to sex and age. RESULTS: Between 2000 and 2010, the prescriptions of at least one drug or one chronic drug increased by 2 % (from 88.0 to 90.3 %; p < 0.0001) and 8 % (from 73.8 to 82.0 %; p < 0.0001), respectively, while the mean number of packages/person/year rose from 34.6 [standard deviation (SD) 32.4] to 48.5 (SD 42.2). During this same period, there was a 10 % increase in the prevalence of elderly people exposed to polypharmacy (≥5 different active substances) (from 42.8 to 52.7 %; p < 0.0001), and the prevalence of those exposed to chronic polypharmacy (≥5 different chronic drugs) doubled (from 14.9 to 28.5 %; p < 0.0001). Males were less frequently treated than females, except for chronic polypharmacy. People aged ≥80 years showed the largest increase in all prescribing patterns. Drug consumption in ATC groups A, H, and N (women) and in B and C (men) increased most, with the greatest absolute differences occurring in the consumption of proton pump inhibitors (31.1 %), platelet aggregation inhibitors (30.1 %), and statins (23.8 %). CONCLUSION: Prescriptions to community-dwelling elderly people have increased substantially during the last 10 years. Although this might indicate an improvement in care, the large increase in the number of elderly people exposed to polypharmacy and chronic polypharmacy should be carefully analyzed in terms of quality of care, patient safety, and costs.

Electrocardiographic monitoring for new prescriptions of quetiapine co-prescribed with acetylcholinesterase inhibitors or memantine from 2005 to 2009. A population study on community-dwelling older people in Italy.

PURPOSE: The aims of this study are to analyse, in community-dwelling people aged 65+ living in Italy's Lombardy Region, electrocardiographic (ECG) monitoring for new users of the atypical antipsychotic quetiapine co-prescribed with acetylcholinesterase inhibitors (AChEIs) or memantine and to find independent predictors of ECG monitoring before and after the starting of this prescription. METHODS: The Lombardy Region's administrative health database was used to retrieve prescriptions of ECG exams as well as prevalence rates of subjects aged 65+ who were prescribed such psychotropic drugs from 2005 to 2009. Multivariable analyses were adjusted for age, sex, number of drugs, treatment with beta-blockers, digoxin, verapamil or diltiazem, any antiarrhythmic drug and antidepressants. RESULTS: Overall 2,623 community-dwelling older people started therapy with quetiapine, co-prescribed with AChEIs or memantine, during these 5 years. At least one ECG was performed in 714 cases (27.2 %) in the 6 months before-and in 398 cases (15.2 %) within 3 months after-the starting of this prescription. ECG monitoring was performed both before and after starting quetiapine in only 160 cases (6.1 %). At multivariable analyses, number of drugs taken, beta-blocker and antiarrhythmic drug use were found to be independent correlates of ECG monitoring whereas female sex was associated with a lower probability of receiving an ECG within 3 months after the initiation of quetiapine (odds ratio 0.78, 95 % CI 0.62-0.98). CONCLUSIONS: ECG monitoring for new prescriptions of quetiapine in older people suffering from behavioural and psychological symptoms in dementia was actually performed infrequently, independently of the age of drug users, especially in women. Our results support the need for greater awareness within the medical community of the importance of such ECG monitoring.

Potentially Inappropriate Psychotropic Drugs in Nursing Homes: An Italian Observational Study.

BACKGROUND AND OBJECTIVES: Physicians often face difficulties in selecting appropriate medications for older adults with multiple comorbidities. As people age, they are more likely to be living with a number of chronic conditions (multimorbidity) and be prescribed a high number of medications (polypharmacy). Multimorbidity is frequent in nursing home (NH) residents and the use of potentially inappropriate medications, especially psychotropic drugs, is widespread. This retrospective cross-sectional cohort study examined the frequency of potentially inappropriate psychotropic drugs using the Beers, Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Fit fOR The Aged (FORTA) criteria, and their association with mortality. METHODS: This retrospective cross-sectional cohort study was conducted on a sample of long-term care NHs across Italy. Of the 34 NHs with an electronic medical records system, 27 met the inclusion criteria, with complete web-based case report forms (CRFs). Residents under the age of 65 years were excluded. We calculated the prevalence of potentially inappropriate psychotropics drugs (antipsychotics, antidepressants and anxiolytics/hypnotics) according to three criteria for prescriptive appropriateness. Univariate and multivariate correlations were examined, taking into account age, sex, comorbidities, and the number of psychotropic drugs, to analyse the relationship between inappropriate psychotropic use and mortality rates. The rate of inappropriate psychotropic prescriptions was calculated with the prevalence of residents receiving potentially inappropriate psychotropic drugs according to the three criteria. We used a logistic model to check for a possible predictive relationship between inappropriate use of psychotropics and mortality. The study evaluated differences in prescriptive appropriateness among NHs by analysing the proportions of potentially inappropriately treated residents at the last visit. Differences were compared with the overall sample mean using confidence intervals (CIs) calculated using Wald's method. RESULTS: This study involved 2555 residents, of whom 1908 (74.7% of the total) were treated with psychotropic drugs; 186 (7.3% of the total) were exposed to at least one psychotropic drug considered potentially inappropriate according to the FORTA criteria. Analysis using the Beers criteria showed that 1616 residents (63.2% of the total) received at least one psychotropic drug considered potentially inappropriate. In line with the Beers recommendation, patients receiving at least three psychotropic drugs were also included and 440 were identified (17.2% of the total sample). According to the STOPP criteria, 1451 residents (56.8% of the total sample) were prescribed potentially inappropriate psychotropic drugs. No correlation was found between potentially inappropriate use of psychotropic drugs and mortality, in either univariate analysis or in a multivariate model adjusted for age, sex and comorbidity index. CONCLUSIONS: Different criteria for appropriate drug prescription identify very different percentages of patients in NHs exposed to psychotropics considered potentially inappropriate. The Beers and STOPP/START criteria identified a larger percentage of patients exposed in NHs than FORTA.