Factors associated to potentially inappropriate prescribing in older patients according to STOPP/START criteria: MoPIM multicentre cohort study.

OBJECTIVES: The objectives of the present analyses are to estimate the frequency of potentially inappropriate prescribing (PIP) at admission according to STOPP/START criteria version 2 in older patients hospitalised due to chronic disease exacerbation as well as to identify risk factors associated to the most frequent active principles as potentially inappropriate medications (PIMs). METHODS: A multicentre, prospective cohort study including older patients (≥65) hospitalized due to chronic disease exacerbation at the internal medicine or geriatric services of 5 hospitals in Spain between September 2016 and December 2018 was conducted. Demographic and clinical data was collected, and a medication review process using STOPP/START criteria version 2 was performed, considering both PIMs and potential prescribing omissions (PPOs). Primary outcome was defined as the presence of any most frequent principles as PIMs, and secondary outcomes were the frequency of any PIM and PPO. Descriptive and bivariate analyses were conducted on all outcomes and multilevel logistic regression analysis, stratified by participating centre, was performed on the primary outcome. RESULTS: A total of 740 patients were included (mean age 84.1, 53.2% females), 93.8% of them presenting polypharmacy, with a median of 10 chronic prescriptions. Among all, 603 (81.5%) patients presented at least one PIP, 542 (73.2%) any PIM and 263 (35.5%) any PPO. Drugs prescribed without an evidence-based clinical indication were the most frequent PIM (33.8% of patients); vitamin D supplement in older people who are housebound or experiencing falls or with osteopenia was the most frequent PPO (10.3%). The most frequent active principles as PIMs were proton pump inhibitors (PPIs) and benzodiazepines (BZDs), present in 345 (46.6%) patients. This outcome was found significantly associated with age, polypharmacy and essential tremor in an explanatory model with 71% AUC. CONCLUSIONS: PIMs at admission are highly prevalent in these patients, especially those involving PPIs or BZDs, which affected almost half of the patients. Therefore, these drugs may be considered as the starting point for medication review and deprescription. TRIAL REGISTRATION NUMBER: NCT02830425.

Emergency Hospital Care for Exacerbation of COPD: Is Inhaled Maintenance Therapy Modified?

BACKGROUND: The impact of hospital emergency care and inward admission for acute exacerbations of COPD on inhaled maintenance treatment is not well known. OBJECTIVE: Therefore, we evaluated the impact of short-stay emergency hospital care and inward admission for acute exacerbation of COPD (eCOPD) on inhaled maintenance treatment prescribed at discharge. DESIGN: Prospective observational cohort study of patients presenting with eCOPD at emergency departments in 16 hospitals of the Spanish healthcare system. The ethics committee at each hospital approved the study and patients provided an informed consent before inclusion. We classified the patients according to the severity of COPD: mild/moderate (FEV1 ≥ 50% predicted) or severe/very severe (FEV1 < 50% predicted) and need of inward hospitalisation. We analysed changes to maintenance treatment on discharge according to GOLD strategy. RESULTS: 1559 patients, 65% required hospitalisation. The most common maintenance treatment was inhaled corticoids (ICS) (80.9%) followed by long-acting beta-agonists (LABA) (75.4%). The most common combination was triple therapy (LABA+ LAMA+ICS) (56.2%) followed by LABA+ICS dual therapy (18.2%) regardless of the severity of COPD. In more than 60% of patients treatment was not changed at discharge. The most common change in treatment was a reduction when discharge was from emergency care and an increase after hospitalisation (-21.6% and +19.5% in severe/very severe COPD, respectively). CONCLUSIONS: Emergency hospital care for eCOPD does not usually induce changes in inhaled maintenance treatment for COPD regardless of the duration of the hospital stay.

The IRYSS-COPD appropriateness study: objectives, methodology, and description of the prospective cohort.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) often experience exacerbations of the disease that require hospitalization. Current guidelines offer little guidance for identifying patients whose clinical situation is appropriate for admission to the hospital, and properly developed and validated severity scores for COPD exacerbations are lacking. To address these important gaps in clinical care, we created the IRYSS-COPD Appropriateness Study. METHODS/DESIGN: The RAND/UCLA Appropriateness Methodology was used to identify appropriate and inappropriate scenarios for hospital admission for patients experiencing COPD exacerbations. These scenarios were then applied to a prospective cohort of patients attending the emergency departments (ED) of 16 participating hospitals. Information was recorded during the time the patient was evaluated in the ED, at the time a decision was made to admit the patient to the hospital or discharge home, and during follow-up after admission or discharge home. While complete data were generally available at the time of ED admission, data were often missing at the time of decision making. Predefined assumptions were used to impute much of the missing data. DISCUSSION: The IRYSS-COPD Appropriateness Study will validate the appropriateness criteria developed by the RAND/UCLA Appropriateness Methodology and thus better delineate the requirements for admission or discharge of patients experiencing exacerbations of COPD. The study will also provide a better understanding of the determinants of outcomes of COPD exacerbations, and evaluate the equity and variability in access and outcomes in these patients.

Association of low serum 25-hydroxyvitamin D levels and high arterial blood pressure in the elderly.

BACKGROUND: Vitamin D and calcium metabolism are involved in vascular smooth muscle cell proliferation, endothelial function and blood pressure (BP) regulation. Their physiopathology has been a matter of intensive clinical investigation with variable and sometimes contradictory results. Vitamin D insufficiency is highly prevalent in the general population, particularly among the elderly. We evaluated the association between serum 25(OH)-D levels and arterial BP in this population. METHODS: An epidemiological cross-sectional study was designed to analyse the prevalence of hypovitaminosis D ('D'AVIS' study) in our reference area. The study was performed on a representative random sample of the population over 64 years of age obtained from five primary health care areas. A medical record, arterial BP and biological analysis: serum 25(OH)-D, iPTH, creatinine, urea, calcium, albumin were obtained. RESULTS: A total of 237 subjects (53% women), aged between 64 and 93 (mean 71.7 +/- 5.3), were evaluated. The mean serum 25(OH)-D levels were 17.21 +/- 7.57 ng/ml (interval 5-54; 86% had <25 ng/ml). The mean BP was 138.8 +/- 14/80 +/- 7.4 mmHg, and 46% were on antihypertensive treatment. A significant negative association was observed between serum 25(OH)-D levels and systolic (r = -0.153, P = 0.018) and diastolic BP (r = -0.152, P = 0.019). This association persisted after controlling for possible confounders in the multivariate analyses. CONCLUSIONS: Low serum 25(OH)-D levels were inversely and independently associated with BP. Supplemental measures to prevent hypovitaminosis D in this population would be important, not only to protect the skeletal system but also for the possible beneficial effects on the cardiovascular system and the BP regulation.

[Hypovitaminosis D associated to low sun exposure in the population over 64 years old]. / Hipovitaminosis D asociada a exposición solar insuficiente en la población mayor de 64 años.

BACKGROUND AND OBJECTIVE: To identify the factors related to hypovitaminosis D in the population over 64 years of age without known risk factors of hypovitaminosis D. SUBJECTS AND METHOD: It was a cross-sectional population study in individuals over 64 year-old attending basic healthcare areas in our hospital's area of reference. A survey was conducted to assess various items (functional capacity, exposure to sun, walks, eating habits). Blood samples taken from each participant were analyzed. RESULTS: A total of 239 individuals -mean age (standard deviation): 72 (5.4) years- were evaluated. 95% of the participants scored > 90 on the Barthel index. Mean serum 25-hydroxyvitamin D3 -25(OH)D3- concentration was 17 (7.5) ng/ml and intact parathormone was 60 (26 pg/ml). The prevalence of hypovitaminosis D was 87%, including 70.3% with insufficiency (25(OH)D3 between 11 and 25 ng/ml) and 16.7% with deficiency (25(OH)D3 < or = 10 ng/ml). The intake of vitamin D and calcium were below recommended levels. The principal source of vitamin D was oily fish. Participants with deficiency scored lower on the Barthel index, had a higher mean age, lived in flats, had less exposure to sun, and used to walk less in sun-hours. Higher levels of alkaline phosphatase and intact parathormone were found in participants with deficiency. The variables independently and significantly associated with vitamin D deficiency were a Barthel score < or = 90, scant exposure to sun and living in a flat. CONCLUSIONS: There is a high prevalence of hypovitaminosis D in the population aged over 64 years in our area, which is associated with lower functional capacity, scant exposure to sun and living in flats.