Patterns of inappropriate prescribing and clinical characteristics in patients at admission to an acute care of the elderly unit.

PURPOSE: Inappropriate prescribing (IP) is common among the elderly and is associated with adverse health outcomes. The role of different patterns of IP in clinical practice remains unclear. The aim of this study is to analyse the characteristics of different patterns of IP in hospitalized older adults. METHODS: This is a prospective observational study conducted in the acute care of elderly (ACE) unit of an acute hospital in Barcelona between June and August 2021. Epidemiological and demographic data were collected, and a comprehensive geriatric assessment (CGA) was performed on admitted patients. Four patterns of inappropriate prescribing were identified: extreme polypharmacy (10 or more drugs), potentially inappropriate medications (PIMs), potential prescribing omissions (PPOs) and anticholinergic burden. RESULTS: Among 93 admitted patients (51.6% male, mean age of 82.83), the main diagnosis was heart failure (36.6%). Overprescribing patterns (extreme polypharmacy, PIMs, PPOs and anticholinergic burden) were associated with higher comorbidity, increased dependence on instrumental activities of daily living (IADL) and greater prevalence of dementia. Underprescribing (omissions) was associated with important comorbidity, residence in nursing homes, an increased risk of malnutrition, higher social risk and greater frailty. Comparing different patterns of IP, patients with high anticholinergic burden exhibited more extreme polypharmacy and PIMs. In the case of omissions, no association was identified with other IP patterns. CONCLUSIONS: We found statistically significant association between patterns of inappropriate prescribing and clinical and CGA variables such as comorbidity, dependency, dementia or frailty. There is a statistically significant association between patterns of overprescribing among patients admitted to the ACE unit.

Integrated health intervention on polypharmacy and inappropriate prescribing in elderly people with multimorbidity: Results at the end of the intervention and at 6 months after the intervention

Background and objective: To analyse the impact of an integrated health intervention focused on polypharmacy and inappropriate prescribing (IP) in elderly people with multimorbidity.Material and methodsPatients were referred for assessment and intervention from primary care or hospital to an interdisciplinary team composed of primary and hospital medical staff and nurses. Pharmacological assessment was centred on polypharmacy and IP using the STOPP/START criteria. Changes in polypharmacy and in IP were analysed at the end of the intervention and at 6 months.ResultsOne hundred consecutive patients (mean (SD) age 81.5(8.0) years, 54(54%) male) were analysed. Mean prescribed medicines at baseline was > 10. There were no significant changes at the end of the intervention and at 6 months. The proportion of patients with two or more STOPP criteria reduced from 37% at the beginning of the intervention to 18% at the end (p< .001), and the proportion of those with START criteria from 13% to 6% (p = .004). These differences persisted at 6 months. The number of STOPP and START criteria before the intervention was associated with a decrease in the STOPP and START criteria at the end of the intervention and at 6 months. A reduction in polypharmacy (p= .041) and in falls (p= .034) was observed at 6 months in those with a decrease in the STOPP criteria at the end of the intervention.ConclusionsAn integrated health intervention centred on polypharmacy and IP in elderly people improves inappropriate prescribing that persists beyond the intervention. (AU)

Fundamento y objetivo: Analizar el impacto de una intervención sanitaria integrada centrada en la polifarmacia y la prescripción inapropiada (PI) en pacientes de edad avanzada con multimorbilidad.Material y métodosLos pacientes fueron remitidos desde la atención primaria o el hospital a un equipo interdisciplinar compuesto por médicos y enfermeras de atención primaria y del hospital para la valoración e intervención. La valoración farmacológica se centró en la polifarmacia y en la PI utilizando los criterios STOPP/START. Se analizaron cambios en la polifarmacia y en la PI al final de la intervención y a los 6 meses.ResultadosSe analizaron 100 pacientes consecutivos con una edad media de 81,5 (8,0) años de los cuales el 54% fueron varones. La media de medicamentos basales fue >10. No hubo diferencias significativas al finalizar la intervención ni a los 6 meses. La proporción de pacientes con 2 o más criterios STOPP se redujo del 37% al comienzo de la intervención al 18% al final (p<0,001), y la proporción de aquellos con criterios START del 13 al 6% (p=0,004). Estos resultados se mantuvieron a los 6 meses. El número de criterios STOPP y START antes de la intervención se asoció a un descenso de los criterios STOPP y START, al final de la intervención y a los 6 meses. En aquellos con una disminución de los criterios STOPP al finalizar la intervención, se observó a los 6 meses una disminución en la polifarmacia (p=0,041) y en las caídas (p=0,034).ConclusionesUna intervención sanitaria integrada centrada en la polifarmacia y en la PI en pacientes de edad avanzada mejora la prescripción inapropiada, y dichas mejoras persisten después de la intervención. (AU)

Integrated health intervention on polypharmacy and inappropriate prescribing in elderly people with multimorbidity: Results at the end of the intervention and at 6 months after the intervention.

BACKGROUND AND OBJECTIVE: To analyse the impact of an integrated health intervention focused on polypharmacy and inappropriate prescribing (IP) in elderly people with multimorbidity. MATERIAL AND METHODS: Patients were referred for assessment and intervention from primary care or hospital to an interdisciplinary team composed of primary and hospital medical staff and nurses. Pharmacological assessment was centred on polypharmacy and IP using the STOPP/START criteria. Changes in polypharmacy and in IP were analysed at the end of the intervention and at 6 months. RESULTS: One hundred consecutive patients (mean (SD) age 81.5(8.0) years, 54(54%) male) were analysed. Mean prescribed medicines at baseline was > 10. There were no significant changes at the end of the intervention and at 6 months. The proportion of patients with two or more STOPP criteria reduced from 37% at the beginning of the intervention to 18% at the end (p< .001), and the proportion of those with START criteria from 13% to 6% (p = .004). These differences persisted at 6 months. The number of STOPP and START criteria before the intervention was associated with a decrease in the STOPP and START criteria at the end of the intervention and at 6 months. A reduction in polypharmacy (p= .041) and in falls (p= .034) was observed at 6 months in those with a decrease in the STOPP criteria at the end of the intervention. CONCLUSIONS: An integrated health intervention centred on polypharmacy and IP in elderly people improves inappropriate prescribing that persists beyond the intervention.

A risk score to predict the absence of left ventricular reverse remodeling: Implications for the timing of ICD implantation in primary prevention.

BACKGROUND: A prophylactic implantable cardioverter defibrillator (ICD) in patients with heart failure and reduced left ventricular ejection fraction (HFrEF) is only indicated when left ventricular ejection fraction (LVEF) reassessment remains ≤35% after 3-6 months on optimal pharmacological therapy. However, LVEF may not improve during this period and the patient may be exposed to an unnecessary risk of sudden cardiac death. This study aimed to determine the incidence and predictors of the absence of left ventricular reverse remodeling (LVRR) after pharmacological treatment optimization in patients with HFrEF to design a risk score of absence of LVRR. METHODS: Consecutive outpatients with LVEF ≤35% were included in this observational prospective study. Up-titration of angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradine was performed in our Heart Failure (HF) Unit. The absence of LVRR was defined as the persistence of an LVEF ≤35% at the 6-month follow-up. RESULTS: One hundred and twenty patients were included. At the 6-month follow-up, 64%, 76%, 72%, and 7% of patients were at 100% of the target dose of ACE inhibitors/ARBs, beta-blockers, MRAs, and ivabradine, respectively. LVRR was observed in 48% of the patients. Ischemic cardiomyopathy, prolonged HF duration, and larger left ventricular end-diastolic diameter index (LVEDDI) were independent predictors of the absence of LVRR. The risk score based on these predictors showed a c-statistic value of 0.81. CONCLUSIONS: Pharmacological treatment optimization is associated with LVRR in approximately half of cases, reducing potential ICD indications in parallel. However, ischemic cardiomyopathy, prolonged HF duration, and larger LVEDDI predict the absence of LVRR and favor ICD implantation without delay. The risk score based on the former predictors may help the clinician with the timing of ICD implantation.

Geriatric Screening Tools to Select Older Adults Susceptible for Direct Transfer From the Emergency Department to Subacute Intermediate-Care Hospitalization.

OBJECTIVES: Early transfer to intermediate-care hospitals, low-tech but with geriatric expertise, represents an alternative to conventional acute hospitalization for selected older adults visiting emergency departments (EDs). We evaluated if simple screening tools predict discharge destination in patients included in this pathway. DESIGN, SETTING, AND PARTICIPANTS: Cohort study, including patients transferred from ED to the intermediate-care hospital Parc Sanitari Pere Virgili, Barcelona, during 14 months (2012-2013) for exacerbated chronic diseases. MEASUREMENTS: At admission, we collected demographics, comprehensive geriatric assessment, and 3 screening tools (Identification of Seniors at Risk [ISAR], SilverCode, and Walter indicator). OUTCOME: Discharge destination different from usual living situation (combined death and transfer to acute hospitals or long-term nursing care) versus return to previous situation (home or nursing home). RESULTS: Of 265 patients (mean age ± SD = 85.3 ± 7.5, 69% women, 58% with acute respiratory infections, 38% with dementia), 80.8% returned to previous living situation after 14.1 ± 6.5 days (mean ± SD). In multivariable Cox proportional hazard models, ISAR >3 points (hazard ratio [HR] 2.06, 95% confidence interval [95% CI] 1.16-3.66) and >1 pressure ulcers (HR 2.09, 95% CI 1.11-3.93), but also continuous ISAR, and, in subanalyses, Walter indicator, increased the risk of negative outcomes. Using ROC curves, ISAR showed the best prediction among other variables, although predictive value was poor (AUC = 0.62 (0.53-0.71) for ISAR >3 and AUC = 0.65 (0.57-0.74) for continuous ISAR). ISAR and SilverCode showed fair prediction of acute hospital readmissions. CONCLUSIONS: Among geriatric screening tools, ISAR was independently associated with discharge destination in older adults transferred from ED to intermediate care. Predictive validity was poor. Further research on selection of candidates for alternatives to conventional hospitalization is needed.

Clinical characteristics and one-year survival in heart failure patients more than 85 years of age compared with younger.

BACKGROUND: Heart failure (HF) is frequent in elderly patients, but few studies have focused on patients older than 84 years. The aim of this study was to evaluate major comorbidities and 1-year survival in HF patients aged ≥85 years compared with younger age groups. METHODS: Patients included in a prospective national registry of HF (RICA) were evaluated. Sociodemographic data, Charlson comorbidity index, cognitive status, basal functional status, body mass index, NYHA functional class, and left ventricle ejection fraction (LVEF) were recorded. Patients aged ≥85 years were compared with the rest using the Cox regression model to detect independent predictive factors of 1-year survival. RESULTS: Of the 1172 patients included, 224 (19%) were aged over 84 years-old, mostly women, with hypertensive heart disease (46%, p<0.001) and preserved LVEF (68.7%; p<0.001). Diabetes (p<0.001), dyslipidemia (p=0.03) and obesity (p<0.001) were less prevalent in this group of patients. One-year mortality in the oldest old patients was 26.3%, which was higher than the rest (p<0.001). By multivariable analysis, a higher NYHA functional class (p=0.038), anemia (p=0.037), absence of obesity (p=0.002), and a worse functional status (p=0.049) were related to a worse 1-year survival in the oldest HF patients. CONCLUSIONS: The oldest old HF patients have differential characteristics with lower prevalence of diabetes, dyslipidemia and obesity and a lower 1-year survival. Independent factors related to a worse 1-year survival in the oldest age group were a higher NYHA class, a worse functional status, presence of anemia and absence of obesity.

Age-related survival and clinical features in systemic sclerosis patients older or younger than 65 at diagnosis.

OBJECTIVE: To analyse the differences in SSc clinical features and survival in patients aged > or = 65 years compared with young SSc patients. METHODS: Of a total of 319 SSc patients, we identified 67 (21%) patients aged >65 years. Demographical data such as SSc subsets, the cutaneous complaint, internal organ involvement and the causes of morbidity and mortality were collected. Results of the elderly and young patients were compared. RESULTS: There were 61 (91%) women and 6 (9%) men aged > or = 65 years. The limited SSc (lSSc) subset was more prevalent in elderly than in young patients (74.6 vs 54%, P = 0.002). Pulmonary disease (86.6% in elderly vs 73.8% in young patients, P = 0.034) and cardiac involvement (70.1% in elderly vs 49.6% in young patients, P = 0.004) were significantly more prevalent in elderly patients. In contrast, signs of oesophageal involvement (43.3% in elderly vs 57.5% in young patients, P = 0.040) were less frequent in aged patients. In addition, pulmonary and heart disease appeared significantly earlier after the diagnosis in patients aged > or = 65 years. Mortality was significantly higher in elderly than in young patients (35.8 vs 19%, P = 0.005), but when standardized mortality ratios (SMRs) were analysed, there was no significant mortality increase in the elderly. CONCLUSION: In elderly patients, the lSSc subset is more prevalent than the diffuse. Pulmonary and cardiac involvement are more prevalent in aged patients and appears sooner after the disease diagnosis. SSc is clearly related to increased mortality, although it is not significant in the elderly group.

Paraneoplastic vasculitis in patients with solid tumors: report of 15 cases.

OBJECTIVE: To review all cases of concurrent vasculitis and solid tumors diagnosed at our Department over a 15-year period and explore evidence that would support the notion of vasculitis being a true paraneoplastic syndrome. METHODS: We reviewed the records of all patients diagnosed with vasculitis and solid tumors within 12 months of each other and prospectively followed until death or our report. We analyzed the main features and outcome of vasculitis in this setting. We also reviewed all cases published in the French-English literature. RESULTS: Fifteen patients (9 men and 6 women) in whom both vasculitis and solid tumor occurred within the same 12 months were identified. Mean age was 72.5 years (range 58-84). In 7 cases the diagnosis of vasculitis antedated that of cancer, in 6 both processes were synchronously diagnosed, and in 2 vasculitis appeared after cancer diagnosis. The most common vasculitis was cutaneous leukocytoclastic vasculitis (n = 9). Other vasculitides included Henoch-Shönlein purpura (n = 2), polyarteritis nodosa (n = 1), and giant cell arteritis (n = 3). The commonest malignancies were carcinomas of urinary organs (40%), lung (26.7%), and gastrointestinal tract (26.7%). The median followup was 28.4 months (range 1-96). Thirteen of the 15 patients demonstrated concordance of disease activity and treatment response for both cancer and vasculitis. Vasculitis flared heralding tumor recurrence or progression in 7 (46.6%) cases. CONCLUSION: In our patients, resolution of vasculitis following effective treatment of the putatively linked malignancy, and recurrence of vasculitis heralding tumor recurrence or progression, provide strong evidence for vasculitis being a true paraneoplastic syndrome. Chronic or persistent vasculitis with poor response to usually effective therapy, especially in elderly patients, should raise questions about underlying malignancy.