Optimizing medical care for geriatric patients in Austria: defining a top five list of "Choosing Wisely" recommendations using the Delphi technique.

PURPOSE: Inappropriate use of diagnostic and therapeutic medical procedures is common and potentially harmful for older patients. The Austrian Society of Geriatrics and Gerontology defined a consensus of five recommendations to avoid overuse of medical interventions and to improve care of geriatric patients. METHODS: From an initial pool of 147 reliable recommendations, 20 were chosen by a structured selection process for inclusion in a Delphi process to define a list of five top recommendations for geriatric medicine. 12 experts in the field of geriatric medicine scored the recommendations in two Delphi rounds. RESULTS: The final five recommendations are concerning urinary catheters in elderly patients, percutaneous feeding tubes in patients with advanced dementia, antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia, and screening for breast, colorectal, prostate, or lung cancer, and the use of antimicrobials to treat asymptomatic bacteriuria. CONCLUSIONS: The selected recommendations have the potential to improve medical care for older patients, to reduce side effects caused by unnecessary medical procedures, and to save costs in the health care system.

DEL-FINE: a new tool for assessing the delirogenic properties of drugs of relevance for European pharmacotherapy.

This article presents a list of potentially delirogenic properties of drugs that are currently of relevance to drug therapy in Europe, which was created through a Delphi process including experts from professions relevant to diagnosis and treatment of delirium. The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) defines delirium as a disturbance in attention, awareness and cognition that develops over a short period of time and fluctuates. Possible causes of delirium are manifold: usually delirium is considered to develop in a multifactorial way, caused by inalterable parameters, such as advanced age and pre-existing cognitive impairment and precipitated by modifiable parameters, such as the use of certain drugs or substance withdrawal. Delirium is a serious condition with a pronounced impact on morbidity, mortality and costs to the healthcare system. Circumstances and drugs that might precipitate or worsen delirium should therefore be avoided whenever possible. A list of drugs that might have a detrimental influence on the emergence and duration of delirium has been created using the terms "delirogenity" and "delirogenic" to describe the potential of a drug or withdrawal to cause or worsen delirium. The results are novel and noteworthy, as their focus is on substances relevant to European pharmacotherapy. Furthermore, they represent a methodical consensus from a group of experts of a wide variety of professions relevant to the prevention, diagnosis and treatment of delirium, such as nursing, pharmacy, pharmacology, surgical and internal medicine, neurology, psychiatry, intensive care and medicine, with working, teaching and scientific experience in several European countries practicing both in primary and secondary care.

Prevalence and associations of potentially inappropriate prescriptions in Austrian nursing home residents: secondary analysis of a cross-sectional study.

BACKGROUND: Potentially inappropriate prescriptions (PIP) are an important cause of adverse medication-related events and increases morbidity, hospitalization, and health care costs, especially in nursing home residents. However, little is known about the associations between PIP and residents' characteristics. OBJECTIVE: The aim of our study was to analyse the prevalence and associations of PIP with residents' and facilities' characteristics. METHODS: We performed a secondary analysis of a cross-sectional study with 48 out of 50 eligible nursing homes and 1,844 out of 2,005 eligible residents in a defined rural-urban area in Austria. The Austrian list of potentially inappropriate medications was applied for the evaluation of inappropriate prescribing. Cluster-adjusted multiple regression analysis was used to investigate institutional and residents' characteristics associated with PIP. RESULTS: Mean cluster-adjusted prevalence of residents with at least one PIP was 70.3 % (95 % CI 67.2-73.4). The number of residents with at least one psychotropic PIP was 1.014 (55 %). The most often prescribed PIP were Prothipendyl (25.9 % residents), Lorazepam (14.5 %) and Diclofenac (6.1 %). Multiple regression analysis showed an inverse association of PIP with cognitive impairment and significant positive associations with permanent restlessness and permanent negative attitude. The associations of PIP with age and male gender were inconsistent. No significant associations were found for PIP and the ratio of staff nurses to residents. CONCLUSIONS: Our study results confirm that PIP is highly prevalent in the nursing home population. These results urgently call for effective interventions. Initiatives and successful interventions performed in other countries could serve as examples for safer prescribing in residents in Austria.

Frequency of medication errors in primary care patients with polypharmacy.

BACKGROUND: Chronic diseases affect more than half of the population ≥75 years of age in developed countries. Prescription medication use increases with age. Depending on definition, 25-80% of elderly are exposed to polypharmacy. Polypharmacy increases the risk of hospitalization, interactions and adverse drug reactions. OBJECTIVE: To examine the frequency of medication errors in patients with polypharmacy treated in general practice. METHODS: The medications of 169 patients with polypharmacy treated in 22 GP surgeries in Austria were analysed. The analysis identified (i) medication errors, including non-evidence-based medications, dosing errors and potentially dangerous interactions in all patients and (ii) potentially inappropriate medications (PIMs) in the subgroup of elderly patients (≥65 years). RESULTS: The patients took on average 9.1±3.0 medications per day. The maximum, in one patient, was 20 medications per day. Some 93.5% had at least one non-evidence-based medication. On average, 2.7±1.66 medications per patient were found to be not indicated. At least one dosing error was found in 56.2% of all patients. One potential interaction of the most severe degree (category X interaction) was detected in 1.8% (n = 3) and two such interactions in 0.6% (n = 1). These combinations should have been avoided. Of the 169 patients, 158 were elderly (≥65 years). Of these seniors, 37.3% (n = 59) had at least one PIM according to the PRISCUS list for the elderly. CONCLUSION: The frequency of medication errors is high in patients with polypharmacy in primary care. Development of strategies (e.g. external medication review) is required to counteract medication errors.

[Pain as adverse drug reaction]. / Die unerwünschte Arzneimittelwirkung Schmerz.

We present a multidisciplinary (anaesthesiology--clinical pharmacy--bioinformatics) analysis of pain as possible adverse drug reaction taking different manifestations of pain, indication groups, relevance to the Austrian drug market and possible mechanistic influence of drugs on development and apprehension of pain into consideration.We designed an overview that shows how transmitters that play a part in nociception and antinociception can be influenced by drugs. This allows conclusions to the dolorigene potential of therapeutics.

Potentially inappropriate medication in geriatric patients: the Austrian consensus panel list.

BACKGROUND: The practice of inappropriate medication and drug prescription is a major risk factor for adverse drug reactions in geriatric patients and increases the individual, as well as overall, rates of hospital admissions, resulting in increased health care expenditures. A consensus-based list of drugs, generally to be avoided in geriatric patients, is a practical tool to possibly improve the quality of prescribing. OBJECTIVE: The aim was to develop a consensus-based list of potentially inappropriate medications (PIM) for geriatric patients in Austria. Local market characteristics and documented prescribing regimens were considered in detail. METHODS: A two-round Delphi process involving eight experts in the field of geriatric medicine was undertaken to create a list of potentially inappropriate medications. Using a 5-point Likert scale (from strong agreement to strong disagreement), mean ratings from the experts were evaluated for each drug selected in the first round. The participants were first asked to comment on the potential inappropriateness of a preliminary list of drugs, and to propose alternate substances missing in the previous questionnaire for a second rating process. All drugs whose upper limit of the 95% CI was less than 3.0 were classified as potentially inappropriate. Drugs with a 95% CI enclosing 3.0 entered a second rating by the experts, in addition to other substances suggested during the first questionnaire. Drugs in the second rating were evaluated in comparable fashion to the first one. The final list was synthesized from the results in both rounds. RESULTS: Out of a preliminary list of 102 drugs, 61 drugs (59.2%) were classified as potentially inappropriate for geriatric persons in the first Delphi- round. In the second rating, six drugs that were reevaluated, and six drugs proposed additionally, were rated as potentially inappropriate. The final list contains 73 drugs to be avoided in older patients because of an unfavorable benefit/risk profile and/or unproven effectiveness. The list also contains suggestions for therapeutic alternatives and information about pharmacological and pharmacokinetic characteristics of all drugs judged as potentially inappropriate. CONCLUSION: The current Austrian list of potentially inappropriate medications may be a helpful tool for clinicians to increase the quality of prescribing in older patients. Like all explicit lists previously published, its validity needs to be proven in validation studies.

[Polypharmacy is of major concern in cardiology]. / Polypharmazie in der Kardiologie - ein beachtliches Problem bei Synkopen, QT-Zeit-Verlängerung, Bradykardie und Tachykardie.

Quality improvement in cardiology over the past decade focused on management of acute coronary syndrome with invasive and innovative medical therapies, optimizing treatment of congestive heart failure and the development of repair procedures in valvular heart disease. On the other hand cardiologist and the attendant physicians are confronted with changes in the characteristics of patients in the light of demographic facts. Comorbidity and polypharmacy raise the need for clear concepts. Therapeutic and diagnostic tools of geriatric medicine may help in that context.

[Oral anticoagulation and risk of bleeding in elderly patients - the aspect of polypharmacy]. / Blutungskomplikationen bei geriatrischen Patienten unter oraler Antikoagulation - Aspekte der Polypragmasie.

Oral anticoagulant therapy has been shown to be of benefit also in elderly patients in various therapeutic and prophylactic indications. Despite strong evidence in literature, doctors still refuse to prescribe oral anticoagulants to geriatric patients in daily routine. Main reason for this decision is the fear of secondary bleeding complications. According to clinical trial data, distinct risk factors for bleeding attributed to anticoagulant treatment may be determined: age >70 years, female gender, recurrent bleeding events, alcohol/drug abuse, diabetes, anaemia and polypharmacy. The entire article reveals the literature in Medline and Cochrane Library from 1980 to 2009 including the hits "polypharmacy - anticoagulant treatment - elderly patients". It further highlights risk assessment strategies in elderly patients, and possible pharmacokinetic and -dynamic interactions of drugs co-administered with oral anticoagulants.

[Diuretics-related complications in elderly patients]. / Komplikationen durch Diuretikatherapie bei geriatrischen Patienten.

Diuretics are well studied and evaluated for their beneficial use in geriatric patients. However those drugs are often used without taking care of subjects condition or functional impairment. Known side effects of those substances may be increased by combinations of multiple drugs. Polypharmacy is a strong risk factor for the incidence of adverse drug reactions (ADR). ADRs are frequently found in combination with the use of diuretics. The remodelling of human body in aging process and uncontrolled therapeutic strategies seem to be causal for that finding. This article tries to work out the potential risk of the usage of those drugs in geriatric patients and its clinical relevance by using literature published in PubMed.

[Drug-related delirium in elderly patients]. / Medikamenten-induzierte Delirien älterer Menschen.

Drugs have been widely associated with the development of delirium in the elderly and represent the most common reversible cause of this condition. This is of importance since successful treatment depends on identifying the reversible contributing factors. Medications with anticholinergic properties, tranquilizers, analgesics and narcotics are common causes of drug-induced delirium. This article provides practical approach to prevent and recognise this condition, reviews the underlying neurotransmitter imbalances and reconsiders age-related changes of pharmacological effects, which may contribute to the development of delirium.

[Polypharmacy and pain treatment]. / Polypharmazie und Schmerztherapie.

Pain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug-drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.

[Polypharmacy and falls in the Elderly]. / Polypharmazie und Stürze im Alter.

Falls and their consequences are a major problem in geriatric medicine. Main causes are the combination of age-related physiological changes with multimorbidity and subsequent polypharmacy. Elderly patients are more susceptible to adverse drug effects and have less compensatory capacity than younger adults. Therefore careful monitoring of side effects is indicated and prescribing for elderly patients calls for alertness in order to identify symptoms as possible adverse drug effects.