Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions.

Background: Polypharmacy paves the way for non-adherence, adverse drug reactions, negative health outcomes, increased use of healthcare services and rising costs. Since it is most prevalent in the older adults, there is an urgent need for introducing effective strategies to prevent and manage the problem in this age group. Purpose: To perform a scoping review critically analysing the available literature referring to the issue of polypharmacy management in the older adults and provide narrative summary. Data sources: Articles published between January 2010-March 2018 indexed in CINHAL, EMBASE and PubMed addressing polypharmacy management in the older adults. Results: Our search identified 49 papers. Among the identified interventions, the most often recommended ones involved various types of drug reviews based on either implicit or explicit criteria. Implicit criteria-based approaches are used infrequently due to their subjectivity, and limited implementability. Most of the publications advocate the use of explicit criteria, such as e.g. STOPP/START, Beers and Medication Appropriateness Index (MAI). However, their applicability is also limited due to long lists of potentially inappropriate medications covered. To overcome this obstacle, such instruments are often embedded in computerised clinical decision support systems. Conclusion: Multiple approaches towards polypharmacy management are advised in current literature. They vary in terms of their complexity, applicability and usability, and no "gold standard" is identifiable. For practical reasons, explicit criteria-based drug reviews seem to be advisable. Having in mind that in general, polypharmacy management in the older adults is underused, both individual stakeholders, as well as policymakers should strengthen their efforts to promote these activities more strongly.

Prevalence of Falls and Associated Factors among Community-Dwelling Older Adults: A Cross-Sectional Study.

AIM: As a person ages, the risk of falls increases, which affects quality of life and represents a financial burden to health- and social-systems, and a greater morbidity and mortality risk. Falls lead to decreased social contact, anxiety, long-term physical disability, severe dependency and hospitalizations. Currently, few studies address this phenomenon using a uniform methodology; therefore, this study aims to explore the prevalence of falls and associated-variables in older adults across Europe. METHODS: In this cross-sectional analysis, we used data from Wave 6 of SHARE. The prevalence of falls was assessed through the answer "falling down" to the question "For the past six months at least, have you been bothered by any of the health conditions on this card?". Multilevel logistic regression was used, using falls as a dependent variable. Multilevel univariable logistic regression models were made to identify potential associated factors. RESULTS: From the 41,098 participants, 56.3% were female, and the average age was of 70.0 ± 8.9 years. The prevalence of falls was 8.2% (CI 8.0% to 8.4%), being higher in women (10.1% vs. 5.8%) and increasing with age. Age, female gender, being frail or pre-frail, higher scores on the EURO-D scale, polypharmacy and fear of falling were found to be significantly associated with falls. CONCLUSIONS: We found that falls are prevalent in the European community-dwelling population, with variations between countries. As a public health priority, identification of the variables associated with falls is important in order to identify/monitor the risk in older groups and develop tailored and cost-effective interventions for falls prevention.

Medication adherence in the older adults with chronic multimorbidity: a systematic review of qualitative studies on patient's experience.

PURPOSE: Medication non-adherence represents a socially relevant challenge, particularly when interlinked to multiple chronic diseases and polypharmacy. Non-adherence rates affect treatment efficacy and increase health care costs. The aim of the study was to identify factors influencing medication adherence in the older adults through a systematic review of qualitative studies on patients' experience. METHODS: Two electronic databases were searched for qualitative studies on medication adherence in chronic diseases (hypertension, heart disease, COPD, asthma) involving people aged 65 + . The systematic review was performed according to the PRISMA statement guidelines, employing theoretical frameworks of the ABC Taxonomy of patient adherence and Three Factor model of determinants of behaviour. RESULTS: The initial database search identified 1234 records, of which 39 studies were considered eligible. Most of the studies focused on hypertension and were conducted in English-speaking countries. According to the ABC Taxonomy, Persistence and Implementation were the most often considered phases. Considering the Three Factor model, the most often reported themes were Information and Strategies upon being adherent. Stemming from the review findings and the patients' narratives, a new integrated model was proposed. It reports the patient's decisional flowchart describing barriers and facilitators (personal, social and environmental) to adherence. CONCLUSION: Medication adherence is a complex and multifaceted process. The implementation of theoretical frameworks along with a patient-centred perspective may provide clinicians with useful suggestions for clinical practice, enhancing the patient's ability to adhere.

Effects of cannabis tetrahydrocannabinol on endocannabinoid homeostasis in human placenta.

Cannabis use has become a hot topic in several countries due to the debate about its legalization for medical purposes. However, data are limited regarding adverse events, safety and potential impact on reproductive health. Cannabis consumption during pregnancy has been associated with gestational disorders such as preterm birth, intrauterine growth restriction, low birth weight and increased risk of miscarriage, though the underlying biochemical mechanisms are still unknown. Given that the endocannabinoid system (ECS) is involved in several reproductive processes, we tested the hypothesis that the negative outcomes may result from the impact on the ECS homeostasis caused by the main psychoactive compound of cannabis, Δ9-tetrahydrocannabinol (THC). We demonstrate that THC (10-40 µM) impairs placental endocannabinoid system by disrupting the endocannabinoid anandamide (AEA) levels and the expression of AEA synthetic and degrading enzymes N-arachidonoylphosphatidylethanolamine-specific phospholipase D (NAPE-PLD) and fatty acid amide hydrolase (FAAH), respectively. Although, no alterations in cannabinoid receptors CB1 and CB2 expression were observed. Thus, long-term local AEA levels are associated with a shift in the enzymatic profile to re-establish ECS homeostasis. In chronic cannabis users, high AEA levels in placenta may disturb the delicate balance of trophoblast cells turnover leading to alterations in normal placental development and foetal growth.