Clinical Implications of Potentially Inappropriate Prescribing According to STOPP/START Version 2 Criteria in Older Polymorbid Patients Discharged From Geriatric and Internal Medicine Wards: A Prospective Observational Multicenter Study.

OBJECTIVES: To evaluate whether STOPP/START v2 potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are associated with 6-month mortality and unplanned hospitalization in hospital-discharged older patients. DESIGN: Multicenter prospective cohort observational study. SETTING AND PARTICIPANTS: Patients aged ≥65 years consecutively discharged from acute geriatric and internal medicine wards of 2 teaching hospitals in northwestern Italy. METHODS: At discharge, a comprehensive geriatric assessment was performed in each patient, prescribed medications were recorded, and PIMs and PPOs were determined according to STOPP/START v2. Death and unplanned readmissions at 6 months were investigated through telephone interviews; variables associated with outcomes were identified in the overall sample and according to discharge setting [ie, home vs medium/long-term care facility (MLTCF)] through a multivariate logistic regression model. RESULTS: Among 611 patients (mean age 81.6 years, 48.4% females, 34.2% MLTCF-discharged, mean number of drugs 7.7 ± 3.2) with a potentially inappropriate prescription (PIP) prevalence at discharge of 71.7% (PIMs 54.8%, PPOs 47.3%), mortality and unplanned readmission rates were 25.0% and 30.9%. Neither PIMs nor PPOs were associated with overall mortality. A higher number of PIMs was significantly associated with unplanned readmission in the overall sample [odds ratio (OR) 1.23, 95% confidence interval (CI) 1.03-1.46] and in home-discharged patients (OR 1.38, 95% CI 1.13-1.68). The number of drugs at discharge was associated with unplanned readmissions in the overall sample (OR 1.11, 95% CI 1.05-1.18) and in MLTCF-discharged patients (OR 1.27, 95% CI 1.13-1.42). PPOs were not significantly associated with clinical outcomes. CONCLUSIONS/IMPLICATIONS: In hospital-discharged older patients with polymorbidity, 6-month unplanned readmissions were associated with a higher number of PIMs in home-discharged patients and with number of drugs in MLTCF-discharged patients. This reaffirms the importance of performing a systematic and careful review of medication appropriateness in hospital-discharged older patients.

Prevalence and predictors of inappropriate prescribing according to the Screening Tool of Older People's Prescriptions and Screening Tool to Alert to Right Treatment version 2 criteria in older patients discharged from geriatric and internal medicine wards: A prospective observational multicenter study.

AIM: To evaluate the prevalence and predictors of potentially inappropriate medications (PIM) and potential prescribing omissions (PPO) in hospital-discharged older patients, according to the recently updated Screening Tool of Older People's Prescriptions and Screening Tool to Alert to Right Treatment version 2 criteria. METHODS: This was a multicenter prospective observational study of patients aged ≥65 years consecutively discharged from geriatric and internal medicine wards. Each patient underwent a comprehensive geriatric assessment, and PIM and PPO at discharge were determined according to the Screening Tool of Older People's Prescriptions and Screening Tool to Alert to Right Treatment version 2 criteria. A multivariate logistic regression was carried out to identify variables independently associated with PIM and PPO. RESULTS: Among 726 participants (mean age 81.5 years, 47.8% women), the prevalence of PIM and PPO were 54.4% and 44.5%, respectively. Benzodiazepines and proton-pump inhibitors were the drugs most frequently involved with PIM, whereas PPO were often related to 5-alpha reductase inhibitors, angiotensin-converting enzyme inhibitors, statins and drugs for osteoporosis. The number of medications (OR 1.22, 95% CI 1.15-1.28) and discharge from geriatric units (OR 0.55, 95% CI 0.40-0.75) were associated with PIM, whereas PPO were independently associated with discharge from geriatric wards (OR 0.44, 95% CI 0.31-0.62), age (OR 1.04, 95% CI 1.02-1.07), comorbidities (OR 1.17, 95% CI 1.04-1.30) and the number of drugs (OR 1.12, 95% CI 1.05-1.18). CONCLUSIONS: Inappropriate prescribing is highly prevalent among hospital-discharged older patients, and is associated with polypharmacy and discharge from internal medicine departments. Geriatr Gerontol Int 2019; 19: 5-11.

Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope.

BACKGROUND: Long QT and use of QT-prolonging drugs are common among older patients receiving polytherapies, but real-world evidence on their impact in clinical practice is controversial. We investigated prevalence, variables associated and clinical implications of prolonged corrected QT (QTc) among patients from the Syncope and Dementia study. METHODS: Observational, prospective, multicenter study. Patients≥65 years with dementia and fall suspected for syncope in the previous three months were enrolled. Several clinical variables and the complete list of medications were recorded for each patient. A 12­lead ECG was obtained and corrected QT was calculated by the Bazett's formula. One-year followup for death and recurrent syncope was performed. RESULTS: Prolonged QTc was observed in 25% of the 432 enrolled patients (mean age 83.3), and was significantly associated with male gender (OR 2.09; 95% CI 1.34-3.26) and diuretics use (OR 1.85; 95% CI 1.18-2.90). At one-year 23.3% of patients died and 30.4% reported at least one recurrent event. Variables associated with one-year mortality were: age, male gender, atrial fibrillation (AF), use of calcium channel blockers and prolonged QTc (OR 1.80; 95% CI 1.01-3.20). Among patients with prolonged QTc a significant interaction for mortality was found with AF. Recurrent events were associated with the use of antiplatelets, cholinesterase. inhibitors and antipsychotics, but not with prolonged QTc. CONCLUSIONS: We documented a high prevalence of prolonged QTc, that was associated with male gender and diuretics but not with psychoactive medications. Patients with prolonged QTc had higher one-year mortality, that was four-fold increased in those with concomitant AF.

Extent of, and variables associated with, blood pressure variability among older subjects.

BACKGROUND: Blood pressure variability (BPV) may have prognostic implications for cardiovascular risk and cognitive decline; however, BPV has yet to be studied in old and very old people. AIMS: Aim of the present study was to evaluate the extent of BPV and to identify variables associated with BPV among older subjects. METHODS: A retrospective study of patients aged ≥ 65 years who underwent 24-h ambulatory blood pressure monitoring (ABPM) was carried out. Three different BPV indexes were calculated for systolic and diastolic blood pressure (SBP and DBP): standard deviation (SD), coefficient of variation (CV), and average real variability (ARV). Demographic variables and use of antihypertensive medications were considered. RESULTS: The study included 738 patients. Mean age was 74.8 ± 6.8 years. Mean SBP and DBP SD were 20.5 ± 4.4 and 14.6 ± 3.4 mmHg. Mean SBP and DBP CV were 16 ± 3 and 20 ± 5%. Mean SBP and DBP ARV were 15.7 ± 3.9 and 11.8 ± 3.6 mmHg. At multivariate analysis older age, female sex and uncontrolled mean blood pressure were associated with both systolic and diastolic BPV indexes. The use of calcium channel blockers and alpha-adrenergic antagonists was associated with lower systolic and diastolic BPV indexes, respectively. CONCLUSIONS: Among elderly subjects undergoing 24-h ABPM, we observed remarkably high indexes of BPV, which were associated with older age, female sex, and uncontrolled blood pressure values.

Prevalence, predictors and clinical impact of potentially inappropriate prescriptions in hospital-discharged older patients: A prospective study.

AIM: Potentially inappropriate prescriptions (PIP) have been highly reported in older patients, but few studies have investigated their association with adverse clinical outcomes. The present study aimed to evaluate the prevalence and predictors of PIP in hospital-discharged older adults, and to explore the association of PIP with death and rehospitalization. METHODS: We carried out a multicenter prospective cohort study on hospital-discharged patients aged ≥65 years. Each patient underwent a comprehensive geriatric assessment, and the prevalence of PIP was obtained by applying Beers Criteria 2015 to discharge documents. Telephone follow up was carried out at 6 months. RESULTS: The prevalence of PIP was 63%, and was associated with psychiatric-behavioral disorders (OR 1.64), the number of daily taken medications (OR 1.08) and long-term care discharge (OR 1.91), whereas better functional performance was protective (OR 0.93). Neither the presence nor the number of PIP were associated with rehospitalization or mortality at 6 months. However, insulin sliding scale (OR 4.97) and use of drugs inappropriate in heart failure (OR 4.64) were associated with an increased risk of rehospitalization, whereas prescription of digoxin ≥0.125 mg/daily (OR 1.77) and antipsychotics (OR 1.65) were associated with a higher risk of mortality. CONCLUSIONS: Among older hospital-discharged patients, we documented a high prevalence of PIP that was significantly associated with polytherapy, the presence of psychiatric-behavioral disorders and discharge to long-term care facilities. Although the presence and the number of PIP were not associated with adverse outcomes, some specific inappropriate prescriptions were associated with a higher risk of hospital readmission and death. Geriatr Gerontol Int 2018; 18: 561-568.

Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence.

Atrial fibrillation is more frequent in older patients, who have a higher risk of cardioembolic stroke and thromboembolism. Oral anticoagulant therapy is the standard of treatment for stroke prevention; however, under-prescription is still very common in older patients. The reasons underlying this phenomenon have not been systematically investigated, and true contraindications only partially account for it. An intimate skepticism on the real benefit-risk balance of oral anticoagulant therapy in the oldest patients seems to derive from the fact that most studies supporting it were conducted decades ago and included younger patients, with overall better functional and clinical status. In this review we will focus on the main barriers to anticoagulant therapy prescription in older patients and summarize the available evidences on the efficacy and safety of vitamin K antagonists and direct oral anticoagulants in this population. The encouraging evidence of a higher net clinical benefit of direct oral anticoagulants compared with warfarin should hopefully widen the treatment options also for frail individuals, thereby allowing a greater number of patients to be treated according to current international guidelines.

Health status, geriatric syndromes and prescription of oral anticoagulant therapy in elderly medical inpatients with atrial fibrillation.

AIM: The aim of the present study was to investigate the prevalence of geriatric syndromes among older medical inpatients with atrial fibrillation, and their association with use of vitamin K antagonists. METHODS: A retrospective study of patients aged ≥65 years discharged with a diagnosis of atrial fibrillation from the Acute Geriatric Ward was carried out. Stroke and bleeding risk were evaluated according to the CHA2 DS2 -VASC and HAS-BLED scores. Comorbidity, cognitive status, functional autonomy and contraindications to vitamin K antagonists were also considered. RESULTS: Atrial fibrillation was documented in 1078 of 3650 patients (29.5%, mean age 83.4 ± 6.6 years, 60.3% women). Contraindications to vitamin K antagonists were documented in 24.9% of patients. Prescription of vitamin K antagonists at discharge was 37.8% and 47.9%, in the overall sample and in those without contraindications, respectively. In the overall sample, prescription of vitamin K antagonists was associated with younger age, permanent/persistent atrial fibrillation, home discharge, less comorbidity, higher hemoglobin levels, better functional independence, known atrial fibrillation at admission and lower HAS-BLED score. Among patients without contraindications to vitamin K antagonists, their use at discharge was independently associated with younger age, permanent/persistent atrial fibrillation, home discharge, higher hemoglobin levels and CHA2DS2-VASC score, better functional autonomy, and greater number of drugs. CONCLUSIONS: We showed a high prevalence of atrial fibrillation among older medical inpatients, who have a poor health status and a high prevalence of geriatric syndromes. Vitamin K antagonists were prescribed in less than half of the patients; underuse was mainly accounted for by a high prevalence of comorbidities/contraindications, poor health status and limited functional autonomy. Geriatr Gerontol Int 2017; 17: 416-423.

Effects of oral anticoagulant therapy in older medical in-patients with atrial fibrillation: a prospective cohort observational study.

BACKGROUND: Uncertainties about efficacy and safety of oral anticoagulant therapy (OAT) among older and frail medical patients with atrial fibrillation (AF) largely contribute to under-prescription of these drugs. AIMS: In this prospective observational cohort study, we investigated mortality, and ischemic and hemorrhagic events, in hospital-discharged older patients with AF. METHODS: Stroke and bleeding risk were evaluated using CHA2DS2-VASC and HAS-BLED scores. Comorbidity, frailty, cognitive and nutritional status and functional autonomy were evaluated using standardized scales. Independent associations between clinical variables, including OAT use, and all-cause mortality, fatal and non-fatal ischemic and hemorrhagic events, were evaluated. Further clinical outcomes comparison between patients treated with OAT and those untreated was performed after adjustment for significant differences in patient baseline characteristics with propensity score matching. RESULTS: Of 452 patients included (mean age 81.6 years, 54.9 % women, roughly 30 % cognitively impaired and/or functionally dependent, mean CHA2DS2-VASC and HAS-BLED scores 4.6 and 2.8, respectively), 151 (33.4 %) died during a mean follow-up period of 300.5 days; ischemic and hemorrhagic stroke occurred in 4.0 and 0.4 % of patients, respectively, and major bleedings in 6.2 %. DISCUSSION: After multivariate analysis, OAT at discharge was associated with lower overall mortality and reduced occurrence of ischemic stroke, the first finding being confirmed in propensity score matched analysis. CONCLUSIONS: Among older vulnerable AF patients with high post discharge death rate, OAT was associated, among other multiple factors, with reduced mortality and lower occurrence of ischemic stroke.

Effects of Oral Anticoagulant Therapy in Medical Inpatients ≥65 Years With Atrial Fibrillation.

In this retrospective cohort observational study, we investigated mortality, ischemic, and hemorrhagic events in patients ≥65 years with atrial fibrillation consecutively discharged from an Acute Geriatric Ward in the period 2010 to 2013. Stroke and bleeding risk were evaluated using CHA2DS2-VASC (congestive heart failure/left ventricular dysfunction, hypertension, aged ≥75 years, diabetes mellitus, stroke/transient ischemic attack/systemic embolism, vascular disease, aged 65 to 74 years, gender category) and HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly) scores. Co-morbidity, cognitive status, and functional autonomy were evaluated using standardized scales. Independent associations among clinical variables, including use of vitamin K antagonist-based oral anticoagulant therapy (OAT), all-cause mortality, and fatal and nonfatal ischemic and hemorrhagic events, were evaluated. Further clinical outcomes comparison between patients treated with OAT and those untreated was performed after adjustment for significant differences in patient baseline characteristics with propensity score matching. Of 980 patients discharged (mean age 83 years, 60% women, roughly 30% cognitively impaired or functionally dependent, mean CHA2DS2-VASC and HAS-BLED scores 4.8 and 2.1, respectively), 505 (51.5%) died during a mean follow-up period of 571 days; ischemic and hemorrhagic stroke occurred in 82 (12.3%) and 13 patients (1.3%), respectively, and major bleedings in 43 patients (4.4%). Vitamin K antagonists' use was independently associated with reduced mortality (odds ratio 0.524) and with a nonsignificant reduction in incidence of ischemic stroke, without excess in bleeding risk. Similar findings were observed in the 2 propensity score-matched cohorts of patients. In conclusion, among vulnerable patients with atrial fibrillation ≥65 years with high post-discharge death rate, OAT was associated, among other multiple factors, with reduced mortality.

Prevalence of and factors associated with prolonged length of stay in older hospitalized medical patients.

AIM: To characterize elderly medical patients and identify factors associated with prolonged length of stay. METHODS: The present prospective observational study evaluated consecutive patients aged ≥65 years admitted in acute geriatric and medical wards. A comprehensive assessment including demographic, clinical, functional and cognitive variables was carried out. Delayed discharge was defined when patients were discharged later than the date they were deemed medically ready for discharge by physicians. The analysis was initially carried out on the total sample and subsequently according to whether hospital admission had been from home, or from intermediate or long-term facilities. RESULTS: Among 1568 patients (age 81.3 ± 7.3 years, 712 men), we observed a high prevalence of functional dependence, cognitive impairment, chronic immobilization and frailty (50%, 25%, 20% and 40%, respectively). Overall, delayed discharge occurred in 442 cases - resulting in 2637 days of prolonged hospital stay - and was independently associated with impairment in activities of daily living, frailty, high comorbidity and inappropriate admission. Among patients admitted from home (roughly 90% of the sample), delayed discharge occurred in 392 patients, and was independently associated with cognitive impairment, functional dependence, low severity of comorbidity and inappropriate admission (OR 3.39). Among patients admitted from intermediate or long-term facilities, lower cognitive impairment and greater severity of functional dependence were independently associated with prolonged stay. CONCLUSIONS: Poor health conditions and high prevalence of geriatric syndromes are extremely common among older medical inpatients. Delayed discharge was mainly observed in patients admitted from home, and associated with cognitive impairment (OR 1.12) and functional dependence (OR 1.49).