Do-Not-Resuscitate Orders in Older Adults During Hospitalization: A Propensity Score-Matched Analysis.

OBJECTIVES: To explore the effect of the presence and timing of a do-not-resuscitate (DNR) order on short-term clinical outcomes, including mortality. DESIGN: Retrospective cohort study with propensity score matching to enable direct comparison of DNR and no-DNR groups. SETTING: Large, academic tertiary-care center. PARTICIPANTS: Hospitalized medical patients aged 65 and older. MEASUREMENTS: Primary outcome was in-hospital mortality. Secondary outcomes included discharge disposition, length of stay, 30-day readmission, restraints, bladder catheters, and bedrest order. RESULTS: Before propensity score matching, the DNR group (n=1,347) was significantly older (85.8 vs 79.6, p<.001) and had more comorbidities (3.0 vs 2.5, p<.001) than the no-DNR group (n=9,182). After propensity score matching, the DNR group had significantly longer stays (9.7 vs 6.0 days, p<.001), were more likely to be discharged to hospice (6.5% vs 0.7%, p<.001), and to die (12.2% vs 0.8%, p<.001). There was a significant difference in length of stay between those who had a DNR order written within 24 hours of admission (early DNR) and those who had a DNR order written more than 24 hours after admission (late DNR) (median 6 vs 10 days, p<.001). Individuals with early DNR were less likely to spend time in intensive care (10.6% vs 17.3%, p=.004), receive a palliative care consultation (8.2% vs 12.0%, p=.02), be restrained (5.8% vs 11.6%, p<.001), have an order for nothing by mouth (50.1% vs 56.0%, p=.03), have a bladder catheter (31.7% vs 40.9%, p<.001), or die in the hospital (10.2% vs 15.47%, p=.004) and more likely to be discharged home (65.5% vs 58.2%, p=.01). CONCLUSION: Our study underscores the strong association between presence of a DNR order and mortality. Further studies are necessary to better understand the presence and timing of DNR orders in hospitalized older adults.

Opiate Prescribing in Hospitalized Older Adults: Patterns and Outcomes.

BACKGROUND/OBJECTIVES: Whereas opiate prescribing patterns have been well described in outpatient and emergency department settings, they have been less defined in hospitalized older adults. The objective was to describe patterns of opiate prescribing and associated outcomes in hospitalized older adults. DESIGN: Retrospective cohort study. SETTING: Tertiary care facility. PARTICIPANTS: Hospitalized medical patients aged 65 and older (N = 9,245; mean age 80.3, 55.2% female, 72.3% white, 90.8% non-Hispanic). MEASUREMENTS: Opiate exposure and duration of action, concurrent use of potentially inappropriate medications (PIMs), adverse events, discharge disposition, length of stay (LOS), and 30-day readmissions. RESULTS: There was no difference in sex, race, ethnicity, or Charlson Comorbidity Index between opiate exposure groups. Participants who had never received opiates had a significantly shorter mean LOS than prior and new opiate users (5.2, 6.8, 7.7 days; P < .001) and were more likely to be discharged home (88.6%, 82.8%, 82.5%; P < .001) and significantly less likely to be readmitted within 30-days (19.6%, 25.0%, 22.3%; P < .001). Participant who had never been exposed to opiates had a significantly shorter mean LOS than those receiving short- and long-acting opiates (5.2, 7.3, 8.6 days; P < .001) and were more likely to be discharged home (88.6%, 82.6%, 82.4%; P < .001) and significantly less likely to be readmitted within 30-days (19.6%, 27.7%, 28.9%; P < .001). CONCLUSION: Opiate use is widespread during hospitalization and is associated with significant negative clinical outcomes and quality metrics. There is an urgent need to develop innovative pain management alternatives to opiate use.

Iatrogenic Adrenal Insufficiency Secondary to Combination Therapy with Elvitegravir/Cobicistat/Tenofovir Disoproxil Fumarate/Emtricitabine and Interlaminar Triamcinolone Injection in an AIDS Patient.

We report the first identified case of suspected iatrogenic adrenal insufficiency after an interlaminar injection of triamcinolone acetonide while on concomitant Stribild (elvitegravir 150 mg/cobicistat 150 mg/tenofovir disoproxil fumarate 300 mg/emtricitabine 200 mg [EVG/c/TDF/FTC]). A 49-year-old female with HIV on EVG/c/TDF/FTC therapy presented to our endocrinology clinic to be evaluated for suspected Cushing syndrome. Prior to presentation, the patient had been given 2 interlaminar spinal injections of triamcinolone. Thereafter, she developed a swollen face, had unexplained weight gain, and fatigue. Cosyntropin stimulation test was positive for adrenal insufficiency. By applying the Naranjo Nomogram for Causality and the Drug Interaction Probability Scale to this drug-drug interaction, we calculated a score of 6 ( probable) and 5 ( probable), respectively. Symptoms resolved without further intervention. The EVG/c/TDF/FTC contains cobicistat, a strong cytochrome P450 3A4 (CYP3A4) inhibitor, which can potentiate drug interactions involving metabolizing of medications via this pathway. Clinicians are reminded to be vigilant while assessing the potential pharmacokinetic drug interactions not mentioned by the manufacturer.