Controlled release of vancomycin from PEGylated fibrinogen polyethylene glycol diacrylate hydrogel.

Surgical site infection (SSI) is a common issue post-surgery which often prolongs hospitalization and can lead to serious complications such as sternal wound infection following cardiac surgery via median sternotomy. Controlled release of suitable antibiotics could allow maximizing drug efficacy and safety, and therefore achieving a desired therapeutic response. In this study, we have developed a vancomycin laden PEGylated fibrinogen-polyethylene glycol diacrylate (PF-PEGDA) hydrogel system that can release vancomycin at a controlled and predictable rate to be applied in SSI prevention. Two configurations were developed to study effect of the hydrogel on drug release, namely, vancomycin laden hydrogel and vancomycin solution on top of blank hydrogel. The relationship between the rigidity of the hydrogel and drug diffusion was found to comply with a universal power law, i.e., softer hydrogels result in a greater diffusion coefficient hence faster release rate. Besides, vancomycin laden hydrogels exhibited burst release, whereas the vancomycin solution on top of blank hydrogels exhibited lag release. A mathematical model was developed to simulate vancomycin permeation through the hydrogels. The permeation of vancomycin can be predicted accurately by using the mathematical model, which provided a useful tool to customize drug loading, hydrogel thickness and stiffness for personalized medication to manage SSI. To evaluate the potential of hydrogels for bone healing applications in cardiovascular medicine, we performed a proof-of-concept median sternotomy in rabbits and applied the hydrogels. The hydrogel formulations accelerated the onset of osteo-genetic processes in rabbits, demonstrating its potential to be used in human.

Exploring the link between comorbidities and Alzheimer's dementia in the Australian Imaging, Biomarker & Lifestyle (AIBL) study.

INTRODUCTION: Mounting evidence suggests that certain comorbidities may influence the clinical evolution of Alzheimer's dementia (AD). METHODS: We conducted logistic regression analyses on the medical history and cognitive health diagnoses of participants in the Australian Imaging, Biomarker & Lifestyle study (n = 2443) to investigate cross-sectional associations between various comorbidities and mild cognitive impairment (MCI)/AD. RESULTS: A mixture of associations were observed. Higher comorbidity of anxiety and other neurological disorders was associated with higher odds of AD, while arthritis, cancer, gastric complaints, high cholesterol, joint replacement, visual defect, kidney and liver disease were associated with lower odds of AD. DISCUSSION: This study underscores the links between specific comorbidities and MCI/AD. Further research is needed to elucidate the longitudinal comorbidity-MCI/AD associations and underlying mechanisms of these associations. Highlights: Comorbidities that significantly increased AD odds included anxiety and other neurological disorders.Arthritis, cancer, gastric complaints, high cholesterol, joint replacement, visual defect, kidney and liver disease were associated with lower odds of AD.Alcohol consumption had the most significant confounding effect in the study.Visual-AD association was modified by age, sex, and APOE ε4 allele status.Anxiety-AD and depression-AD associations were modified by sex.

Exploring the association between cancer and cognitive impairment in the Australian Imaging Biomarkers and Lifestyle (AIBL) study.

An inverse association between cancer and Alzheimer's disease (AD) has been demonstrated; however, the association between cancer and mild cognitive impairment (MCI), and the association between cancer and cognitive decline are yet to be clarified. The AIBL dataset was used to address these knowledge gaps. The crude and adjusted odds ratios for MCI/AD and cognitive decline were compared between participants with/without cancer (referred to as C+ and C- participants). A 37% reduction in odds for AD was observed in C+ participants compared to C- participants after adjusting for all confounders. The overall risk for MCI and AD in C+ participants was reduced by 27% and 31%, respectively. The odds of cognitive decline from MCI to AD was reduced by 59% in C+ participants after adjusting for all confounders. The risk of cognitive decline from MCI to AD was halved in C+ participants. The estimated mean change in Clinical Dementia Rating-Sum of boxes (CDR-SOB) score per year was 0.23 units/year higher in C- participants than in C+ participants. Overall, an inverse association between cancer and MCI/AD was observed in AIBL, which is in line with previous reports. Importantly, an inverse association between cancer and cognitive decline has also been identified.

Immigration and access to dementia diagnostics and treatment: A nationwide study in Sweden.

•Compared to Swedish-born people, foreign-born people were less likely to receive dementia diagnostic tests.•Being born in Africa or Europe was associated with lower chance of receiving cholinesterase inhibitors.•Asian-born people had higher chance of receiving cholinesterase inhibitors, but were less likely to receive memantine.•Disparities existed in dementia diagnostics and treatment between Swedish-born and foreign-born people, but were not consistent after adjusting for MMSE scores.

Prevalence of and Risk Factors for Drug-Related Readmissions in Older Adults: A Systematic Review and Meta-Analysis.

BACKGROUND: Older adults are at an increased risk of drug-related problems, especially following discharge from hospital. Drug-related readmissions place a large burden on the patient and the healthcare system. However, previous studies report inconsistent results on the prevalence and associated risk factors for drug-related hospital readmissions in older adults. OBJECTIVES: We aimed to assess the prevalence of drug-related readmissions in older adults aged 65 years and older and investigate the drug classes, preventability and risk factors most associated with these readmissions. METHODS: A systematic review and meta-analysis were undertaken to answer our objectives. A search of four databases (MEDLINE, Embase, CINAHL and Scopus) was conducted. Three authors independently performed title and abstract screening, full-text screening and data extraction of all included studies. A meta-analysis was conducted to calculate the pooled prevalence of drug-related readmissions across all studies, and a subgroup analysis was performed to explore heterogeneity among studies reporting on adverse drug reaction-related readmissions. RESULTS: A total of 1978 studies were identified in the initial search, of which four studies were included in the final synthesis. Three studies focused on readmissions due to adverse drug reactions and one study focused on readmissions due to drug-related problems. A pooled prevalence of 9% (95% confidence interval 2-18) was found for drug-related readmissions across all studies, and a pooled prevalence of 6% (95% confidence interval 4-10) was found for adverse drug reaction-related readmissions. Three studies explored the preventability of readmissions and 15.4-22.2% of cases were deemed preventable. The drug classes most associated with adverse drug reaction readmissions included anticoagulants, antibiotics, psychotropics and chemotherapy agents. Polypharmacy (the use of five or more medications) and several comorbidities such as cancer, liver disease, ischaemic heart disease and peptic ulcer disease were identified as risk factors for drug-related readmissions. CONCLUSIONS: Almost one in ten older adults discharged from hospital experienced a drug-related hospital readmission, with one fifth of these deemed preventable. Several comorbidities and the use of polypharmacy and high-risk drugs were identified as prominent risk factors for readmission. Further research is needed to explore possible causes of drug-related readmissions in older adults for a more guided approach to the development of effective medication management interventions.

The Impact of Educational Attainment and Income on Long-Term Care for Persons with Alzheimer's Disease and Other Dementias: A Swedish Nationwide Study.

BACKGROUND: Long-term care improves independence and quality of life of persons with dementia (PWD). The influence of socioeconomic status on access to long-term care was understudied. OBJECTIVE: To explore the socioeconomic disparity in long-term care for PWD. METHODS: This registry-based study included 14,786 PWD, registered in the Swedish registry for cognitive and dementia disorders (2014-2016). Education and income, two traditional socioeconomic indicators, were the main exposure. Outcomes were any kind of long-term care, specific types of long-term care (home care, institutional care), and the monthly average hours of home care. The association between outcomes and socioeconomic status was examined with zero-inflated negative binomial regression and binary logistic regression. RESULTS: PWD with compulsory education had lower likelihood of receiving any kind of long-term care (OR 0.80, 95% CI 0.68-0.93), or home care (OR 0.83, 95% CI 0.70-0.97), compared to individuals with university degrees. Their monthly average hours of home care were 0.70 times (95% CI 0.59-0.82) lower than those of persons with university degrees. There was no significant association between education and the receipt of institutional care. Stratifying on persons with Alzheimer's disease showed significant association between lower education and any kind of long-term care, and between income and the hours of home care. CONCLUSIONS: Socioeconomic inequalities in long-term care existed in this study population. Lower-educated PWD were less likely to acquire general long-term care, home care and had lower hours of home care, compared to their higher-educated counterparts. Income was not significantly associated with the receipt of long-term care.

Poisonings in Older People with Dementia: A Systematic Scoping Review and Meta-Analysis.

BACKGROUND: Older people with dementia are at a particularly high risk of poisonings and their subsequent harms. OBJECTIVE: This review aimed to describe the key agents, incidence, risk factors, and disposition of poisonings in people with dementia reported in the literature. METHODS: Medline, Embase, CINAHL, and PsycINFO databases were searched from 1 September 2001 to 1 September 2021. Terms for dementia, poisonings, and older adults formed the search concepts. Quantitative studies published in English, describing poisonings in older people with dementia, including Alzheimer's disease, were included. Two investigators independently assessed articles for eligibility and extracted relevant data. A meta-analysis of the incidence of poisonings in people with dementia across studies was performed. RESULTS: Of 4,579 articles, 18 were included for final synthesis. Nervous system medications were implicated in over half of all medicinal poisonings, with anti-dementia agents, benzodiazepines, and opioids the most common classes. The non-medicinal agents frequently associated with poisonings were personal care and household products. The yearly incidence of poisoning varied across definitions of poisoning from 3% for International Classification of Disease-defined poisonings to 43% for adverse drug event-defined poisonings. Several risk factors were identified, including multimorbidity, psychotropic medication use, and living in residential care. Where described, up to one in five poisonings resulted in hospitalisation and in death. CONCLUSIONS: Poisonings are common in people with dementia, involving commonly prescribed medications or easily accessible substances. Given the significant outcomes associated, further research is required to better understand these poisonings and improve public health strategies to reduce the occurrence of this preventable harm.

Melatonin use in children and adolescents: A scoping review of caregiver perspectives.

Despite melatonin's popularity as a pediatric sleep-aid, little has been investigated around caregivers' understanding and perception of melatonin use for their dependent. This scoping review analyzes the current literature on pediatric melatonin use, to understand how caregivers' perceptions around melatonin are shaped by their illness/medication-related beliefs, treatment experience and preferences. A literature search was conducted across Embase, Medline, PsycINFO, PubMed and Scopus, generating 184 results for screening against the inclusion criteria. Nineteen studies were retrieved, comprising of 1561 children and adolescents, aged 8.7 ± 2.3 years (range: 0-44 years), conducted primarily in the United States of America (n = 6), Canada (n = 3) and the Netherlands (n = 3). Studies were evaluated for their study design and caregiver-centered outcomes, encompassing: 1) illness/treatment-related beliefs, 2) treatment satisfaction/effectiveness, 3) treatment preference/acceptability, and 4) impact of child's sleep disturbance on caregivers' quality-of-life. Sleep disturbances necessitating melatonin use occurred alongside congenital/neurodevelopmental comorbidities in 18 studies (95%). Melatonin was commonly associated with "naturalness" and "safety". Concepts of treatment satisfaction versus effectiveness were minimally differentiated within included studies. Caregivers preferred concurrent use of melatonin and behavioral interventions for management of their dependents' sleep. Improved sleep in the dependent generally led to better quality-of-life for caregivers and their family.

3D printing for personalised medicines: implications for policy and practice.

The current healthcare dynamic has shifted from one-size-fits-all to patient-centred care, with our increased understanding of pharmacokinetics and pharmacogenomics demanding a switch to more individualised therapies. As the pharmaceutical industry remains yet to succumb to the push of a technological paradigm shift, pharmacists lack the means to provide completely personalised medicine (PM) to their patients in a safe, affordable, and widely accessible manner. As additive manufacturing technology has already established its strength in producing pharmaceutical formulations, it is necessary to next consider methods by which this technology can create PM accessible from pharmacies. In this article, we reviewed the limitations of current pharmaceutical manufacturing methods for PMs, three-dimensional (3D) printing techniques that are most beneficial for PMs, implications of bringing this technology into pharmacy practice, and implications for policy surrounding 3D printing techniques in the manufacturing of PMs.

Polypharmacy and trajectories of health-related quality of life in older adults: an Australian cohort study.

BACKGROUND: Health-related quality of life (HRQoL) is an important outcome measure when considering medical treatment; however, the impact of polypharmacy on trajectories of HRQoL over time is unknown. This study aimed to investigate the association between polypharmacy status and trajectories of HRQoL in older adults. METHODS: A longitudinal cohort study of 2181 community-dwelling adults, 65 years and older, who participated in the 2013 to 2017 waves of the Household Income and Labour Dynamics in Australia (HILDA) Survey. Polypharmacy was defined as the regular use of ≥ 5 prescription medications. Polypharmacy status was categorised into no polypharmacy, in 2013 only (baseline only polypharmacy), in 2017 only (incident polypharmacy) or at both time points (persistent polypharmacy). HRQoL was assessed through the SF-36 questionnaire generating two summary scores: physical component summary (PCS) and mental component summary (MCS). Linear mixed-effects models stratified according to polypharmacy status and change in comorbidities were used to assess trajectories of HRQoL. RESULTS: Older adults with persistent polypharmacy had lowest scores for HRQoL measures from 2013 to 2017. After adjusting for all covariates, those with incident polypharmacy had the steepest annual decline in both the PCS and MCS: - 0.86 in PCS and - 0.76 in MCS for those with decreasing or stable comorbidities, and - 1.20 in PCS and - 0.75 in MCS for those with increasing comorbidities. CONCLUSIONS: Polypharmacy was associated with poorer HRQoL, even after adjusting for confounders. Incident polypharmacy was found to be associated with a clinically important decline in HRQoL and this should be considered when prescribing additional medication to older adults.

Prevalence and Risk Factors for Drug-Related Problems in People With Dementia Living in the Community: A Systematic Review and Meta-Analysis.

OBJECTIVES: The aims of this systematic review were to identify the prevalence and risk factors associated with drug-related problems (DRPs) in people living with dementia in the community. DESIGN: A systematic review and meta-analysis. SETTING AND PARTICIPANTS: People with dementia living in the community. METHODS: Six databases (Embase, Medline, PsycINFO, International Pharmaceutical Abstracts, Scopus, and CINAHL) were searched using a combination of keywords and Medical Subject Heading (MeSH) terms with 4 concepts: dementia, older adults, DRPs, and community-dwelling. Primary outcomes were adverse drug reactions (ADRs), adverse drug events (ADEs), and medication errors (MEs). RESULTS: There were 22 studies included: 4 cross-sectional studies and 18 cohort studies. The number of participants in these studies ranged from 81 to 21,795. The pooled prevalence for any ADEs, including ADRs, in people living with dementia was 19.0% (95% CI 11.6%-27.7%), whereas the pooled prevalence for specific types of ADEs ranged from 2.6% to 10.2%. Furthermore, the prevalence of MEs ranged from 0.9% to 41.3%. Psychotropic medications, polypharmacy, and inappropriate medications contributed to an increased risk of experiencing DRPs, whereas support with medication management was a protective factor. CONCLUSIONS AND IMPLICATIONS: The prevalence of overall DRPs experienced by people with dementia was highly variable in included studies. Awareness that certain medication, patient, and medication management factors are associated with the risk of people with dementia experiencing DRPs may guide clinicians to identify high-risk situations and implement suitable mitigation strategies.

Clinical factors associated with increased length of stay and readmission in patients with medication-related hospital admissions: a retrospective study.

BACKGROUND: Adverse drug events (ADEs) remain a key contributor to hospitalisations, resulting in long hospital stays and readmissions. Information pertaining to the specific medications and clinical factors associated with these outcomes is limited. Hence, a better understanding of these factors and their relationship to ADEs is required. OBJECTIVES: To investigate medications involved, clinical manifestations of ADE-related hospitalisations, and their association with length of stay and readmission. METHODS: A retrospective medical record review of patients admitted to a major, tertiary referral hospital in NSW, Australia, from January 2019 to August 2020 was conducted. ADEs were identified using Australian Refined Diagnosis Related Group (AR-DRG) codes: X40, X61, X62 and X64. Medications were classified per the Anatomical Therapeutic Chemical (ATC) classification system and clinical symptoms were classified per the International Classification of Disease (ICD) 9-CM. Logistic regression was performed to assess the relationship between medication and presentation classes with length of stay (≥2 days vs <2 days) and readmission. RESULTS: There were 125 patients who met inclusion criteria (median age = 64 [interquartile range, 45-75] years; 53.6% male). Anti-thrombotic agents, opioids, antidepressants, antipsychotics, insulins and NSAIDs were the most implicated pharmacological classes. Neurological medications and falls were associated with a length of stay ≥2 days (adjusted odds ratio [aOR] 3.92, 95% confidence interval [CI] 1.48-10.33 and aOR 3.24, 95% CI 1.05-10.06, respectively). Neurological medications and neurological and cognitive disorders were associated with an increased likelihood of 90-day readmission (aOR 2.63, 95% CI 1.05-6.57 and aOR 3.20, 95% CI 1.17-8.75, respectively). CONCLUSION: This study identified neurological medications as high-risk for increased length of stay and readmission in those hospitalised due to ADEs. This highlights the need for judicious prescribing and monitoring of these medications.

Validating a model for medication-related dental outcomes in older people.

OBJECTIVES: To externally validate a model for medication-related dental outcomes in (a) a general older population with dementia and (b) a matched population without dementia. SUBJECTS AND METHODS: This validation study used population-based data from seven Swedish national registers (2008-2017). Individuals aged 60+ with dementia were matched to those without dementia on age, gender, and county of residence at the date of diagnosis (index date). The exposure was continuous use of xerogenic medications during the 3-year period before index date. The primary outcome was the number of tooth extraction and restorative procedures within 3 years after index date. RESULTS: A total of 334,220 individuals were included in the final sample. In the dementia cohort, the use of urological drugs (incidence rate ratio [IRR] 1.08, 95% CI 1.03-1.13), respiratory medicines (IRR 1.10, 95% CI 1.04-1.17), and proton-pump inhibitors (IRR 1.09, 95% CI 1.05-1.13) was associated with the primary outcome. In the non-dementia cohort, respiratory medicines (IRR 1.03, CI 1.00-1.05), proton-pump inhibitors (IRR 1.06, CI 1.04-1.08), opioids (IRR 1.05, CI 1.03-1.07), and antidepressants (IRR 1.06, CI 1.04-1.08) were associated with the primary outcome. CONCLUSIONS: Although there were differences in prescription patterns, the model performed similarly in both those with and without dementia.

Influence of Education and Income on Receipt of Dementia Care in Sweden.

OBJECTIVE: To explore the dementia diagnostic process and drug prescription for persons with dementia (PWD) with different socioeconomic status (SES). DESIGN: Register-based cohort study. SETTING AND PARTICIPANTS: This study included 74,414 PWD aged ≥65 years from the Swedish Dementia Register (2007-2018). Their data were linked with the Swedish Longitudinal Integrated Database for Health Insurance and Labor Market Studies (2006-2017) to acquire the SES information 1 year before dementia diagnosis. METHODS: Education and income-2 traditional SES indicators-were divided into 5 levels. Outcomes comprised the dementia diagnostic examinations, types of dementia diagnosis, diagnostic unit, and prescription of antidementia drugs. Binary logistic regression was performed to evaluate socioeconomic inequalities. RESULTS: Compared to PWD with the lowest educational level, PWD with the highest educational level had a higher probability of receiving the basic diagnostic workup [odds ratio (OR) 1.19, 95% confidence interval (CI) 1.10-1.29], clock test (OR 1.12, 95% CI 1.02-1.24) and neuroimaging (OR 1.23, 95% CI 1.09-1.39). Compared with PWD in the lowest income quintile, PWD in the highest income quintile presented a higher chance of receiving the basic diagnostic workup (OR 1.35, 95% CI 1.26-1.46), clock test (OR 1.40, 95% CI 1.28-1.52), blood analysis (OR 1.21, 95% CI 1.06-1.39), Mini-Mental State Examination (OR 1.47, 95% CI 1.26-1.70), and neuroimaging (OR 1.30, 95% CI 1.18-1.44). PWD with higher education or income had a higher likelihood of obtaining a specified dementia diagnosis or being diagnosed at a memory clinic. SES presented no association with prescription of antidementia medication, except for the association between education and the use of memantine. CONCLUSIONS AND IMPLICATIONS: Higher education or income was significantly associated with higher chance of receiving dementia diagnostic examinations, a specified dementia diagnosis, being diagnosed at a memory clinic, and using memantine. Socioeconomic inequalities in dementia diagnostic process and prescription of memantine occurred among PWD with different education or income levels.

The Prevalence and Characteristics of Psychotropic-Related Hospitalizations in Older People: A Systematic Review and Meta-Analysis.

OBJECTIVES: To assess the prevalence and characteristics of psychotropic medication-related hospitalizations in older people. DESIGN: Systematic review with meta-analysis. SETTING AND PARTICIPANTS: Older adults (≥65 years of age) with psychotropic-related hospitalizations. METHODS: A search of published literature was performed in Medline, Embase, CINAHL, and Scopus from 2010 to March 2020. Three authors independently screened titles, abstracts, and full texts of relevant studies for relevance. Two authors independently extracted full text data, including characteristics, measures of causality, prevalence data, and performed quality assessment. A meta-analysis was conducted to estimate pooled prevalence and 95% confidence intervals (CIs) of psychotropic-related hospitalizations using random effects models. Heterogeneity was explored using subgroup analyses. RESULTS: Of 815 potentially relevant studies, 11 were included in the final analysis. Five studies were cross-sectional studies, 5 were cohort studies, and 1 was a case control study. The majority of studies were rated as good quality. Psychotropic medications contributed to 2.1% (95% CI 1.2%-3.3%) of total hospitalizations and 11.3% (95% CI 8.2%-14.8%) of adverse drug event-related hospitalizations. The main psychotropic medications attributable to hospitalizations were antidepressants, hypnotics, sedatives, and antipsychotics. CONCLUSIONS AND IMPLICATIONS: Psychotropic medications are a significant contributor to hospitalizations in older adults. The risk of hospitalization was greatest for those taking antidepressants, antipsychotics, hypnotics, and sedatives. Future studies should aim to address specific medication subgroups and implement uniform adverse drug event-related classification systems to improve comparability across studies.

Hydrogen-methane breath testing results influenced by oral hygiene.

The measurement of hydrogen-methane breath gases is widely used in gastroenterology to evaluate malabsorption syndromes and bacterial overgrowth. Laboratories offering breath testing provide variable guidance regarding oral hygiene practices prior to testing. Given that oral dysbiosis has the potential to cause changes in breath gases, it raises concerns that oral hygiene is not a standard inclusion in current breath testing guidelines. The aim of this study was to determine how a pre-test mouthwash may impact hydrogen-methane breath test results. Participants presenting for breath testing who had elevated baseline gases were given a chlorhexidine mouthwash. If a substantial reduction in expired hydrogen or methane occurred after the mouthwash, breath samples were collected before and after a mouthwash at all breath sample collection points for the duration of testing. Data were evaluated to determine how the mouthwash might influence test results and diagnostic status. In 388 consecutive hydrogen-methane breath tests, modifiable elevations occurred in 24.7%. Administration of a chlorhexidine mouthwash resulted in significantly (p ≤ 0.05) reduced breath hydrogen in 67% and/or methane gas in 93% of those consenting to inclusion. In some cases, this modified the diagnosis. Mean total gas concentrations pre- and post-mouthwash were 221.0 ppm and 152.1 ppm (p < 0.0001) for hydrogen, and 368.9 ppm and 249.8 ppm (p < 0.0001) for methane. Data suggest that a single mouthwash at baseline has a high probability of returning a false positive diagnosis. Variations in gas production due to oral hygiene practices has significant impacts on test interpretation and the subsequent diagnosis. The role of oral dysbiosis in causing gastrointestinal symptoms also demands exploration as it may be an underlying factor in the presenting condition that was the basis for the referral.

Use of Falls Risk Increasing Drugs in Residents at High and Low Falls Risk in Aged Care Services.

Falls are associated with considerable morbidity and mortality in aged care services and falls risk increasing drugs (FRIDs) are often overlooked as a contributor to falls. This study aims to investigate the association between the risk of falling and use of FRIDs from aged care services. Inverse-probability-weighted multinomial logistic regression was used to estimate the association between falls risk and regular FRIDs in 383 residents from six Australian aged care services. Overall, residents at high and low falls risk had similar prevalence of FRIDs. Prevalence of antipsychotics and sedative-hypnotics was low. Residents at high falls risk had higher adjusted odds of using ≥2 psychotropic medications (odds ratio [OR] = 1.75, 95% confidence interval [CI] = 1.17-2.61) and ≥2 medications that cause/worsen orthostatic hypotension (OR = 3.59, 95% CI = 2.27-5.69). High prevalence of FRIDs was mainly attributable to medications for which residents had clinical indications. Clinicians appeared to have largely avoided FRIDs that explicit criteria deem potentially inappropriate for high falls risk.

Medication Management in Frail Older People: Consensus Principles for Clinical Practice, Research, and Education.

Frailty is a geriatric condition associated with increased vulnerability to adverse drug events and medication-related harm. Existing clinical practice guidelines rarely provide medication management recommendations specific to frail older people. This report presents international consensus principles, generated by the Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network, related to medication management in frail older people. This consensus comprises 7 principles for clinical practice, 6 principles for research, and 4 principles for education. Principles for clinical practice include (1) perform medication reconciliation and maintain an up-to-date medication list; (2) assess and plan based on individual's capacity to self-manage medications; (3) ensure appropriate prescribing and deprescribing; (4) simplify medication regimens when appropriate to reduce unnecessary burden; (5) be alert to the contribution of medications to geriatric syndromes; (6) regularly review medication regimens to align with changing goals of care; and (7) facilitate multidisciplinary communication among patients, caregivers, and healthcare teams. Principles for research include (1) include frail older people in randomized controlled trials; (2) consider frailty status as an effect modifier; (3) ensure collection and reporting of outcome measures important in frailty; (4) assess impact of frailty on pharmacokinetics and pharmacodynamics; (5) encourage frailty research in under-researched settings; and (6) utilize routinely collected linked health data. Principles for education include (1) provide undergraduate and postgraduate education on frailty; (2) minimize low-value care related to medication management; (3) improve health and medication literacy; and (4) incorporate evidence in relation to frailty into clinical practice guidelines. These principles for clinical practice, research and education highlight different considerations for optimizing medication management in frail older people. These principles can be used in conjunction with existing best practice guidelines to help achieve optimal health outcomes for this vulnerable population. Implementation of the principles will require multidisciplinary collaboration between healthcare professionals, researchers, educators, organizational leaders, and policymakers.