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1.
BMC Geriatr ; 21(1): 571, 2021 Oct 18.
Artigo em Inglês | MEDLINE | ID: mdl-34663238

RESUMO

BACKGROUND: Drug-drug interactions (DDIs) are highly prevalent in older patients but little is known about prevalence of DDIs over time. Our main objective was to assess changes in the prevalence and characteristics of drug-drug interactions (DDIs) during a one-year period after hospital admission in older people, and associated risk factors. METHODS: We conducted a sub-study of the European OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people), which assessed the effects of a structured medication review (experimental arm) compared to usual care (control arm) on reducing drug-related hospital readmissions. All OPERAM patients (≥70 years, with multimorbidity and polypharmacy, hospitalized in four centers in Bern, Brussels, Cork and Utrecht between December 2016 and October 2018, followed over 1 year) who were alive at hospital discharge and had full medication data during the index hospitalization (at baseline i.e., enrolment at admission, and at discharge) were included. DDIs were assessed using an international consensus list of potentially clinically significant DDIs in older people. The point-prevalence of DDIs was evaluated at baseline, discharge, and at 2, 6 and 12 months after hospitalization. Logistic regression models were performed to assess independent variables associated with changes in DDIs 2 months after baseline. RESULTS: Of the 1950 patients (median age 79 years) included, 1045 (54%) had at least one potentially clinically significant DDI at baseline; point-prevalence rates were 58, 57, 56 and 57% at discharge, and 2, 6 and 12 months, respectively. The prevalence increased significantly from baseline to discharge (P < .001 [significant only in the control group]), then remained stable over time (P for trend .31). The five most common DDIs -all pharmacodynamic in nature- accounted for 80% of all DDIs and involved drugs that affect potassium concentrations, centrally-acting drugs and antithrombotics. At 2 months, DDIs had increased in 459 (27%) patients and decreased in 331 (19%). The main factor predictive of a change in the prevalence of DDIs was hyperpolypharmacy (≥10 medications). CONCLUSIONS: DDIs were very common; their prevalence increased during hospitalization and tended to remain stable thereafter. Medication review may help control this increase and minimize the risk of adverse drug events.

2.
Ageing Res Rev ; 71: 101455, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34487916

RESUMO

During the COVID-19 pandemic older subjects have been disproportionately affected by the disease. Vaccination is a fundamental intervention to prevent the negative consequences of COVID-19, but it is not known if the needs and vulnerabilities of older people are adequately addressed by their inclusion in randomized clinical trials (RCTs) evaluating the efficacy of vaccines for COVID-19. Given this background, we aimed to evaluate if current and ongoing phase II-III RCTs evaluating the efficacy of COVID-19 vaccines included a representative sample of older people. A systematic literature search in PubMed and Clinicaltrials.gov was performed until May 01st, 2021. Among 474 abstracts initially retrieved, 20 RCTs (ten already published, ten ongoing) were included. In the ten studies already published, the mean age of participants was 45.2 ± 11.9 years and only 9.83% of the participants were more than 65 years, 1.66% more than 75 years and less than 1% (0.55%) more than 85 years. In the ten ongoing RCTs, many of the studies aimed at including participants older than 18 years, with one study including participants between 18 and 84 years, and two between 21 and 100 years. In conclusion, our systematic review demonstrates that in published and ongoing phase II-III randomized clinical trials evaluating the efficacy of COVID-19 vaccines only a tiny fraction of the most vulnerable group of older people was included, although they clearly were the first population that had to be vaccinated.


Assuntos
COVID-19 , Vacinas , Idoso , Humanos , SARS-CoV-2
3.
Sr Care Pharm ; 36(9): 444-454, 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34452654

RESUMO

Introduction Major barriers in deprescribing are the ambivalence of patients, resistance to change, and poor acceptance of alternative treatments. Objective To investigate older patients' beliefs, understanding and knowledge, satisfaction with medicine use, health outcome priorities, their attitude toward deprescribing, and to identify associated patient factors. Methods This multi-center cross-sectional, semistructured survey study involved older outpatients (70 years of age and older) with polypharmacy. The survey comprised three validated questionnaires: Beliefs about Medicines Questionnaire, Patients' Attitudes Towards Deprescribing questionnaire, and the Health Outcome Prioritization tool, with additional questions about understanding and satisfaction. The association between questionnaire outcomes and patient characteristics was investigated. Results Fifty participants were included; they used an average of 9 (+/- SD 2.7) medicines. For most participants (82%), the necessity of using medicines outweighed their concerns. Participants could name 35% of their medicines and 43% of the indications. Overall, 76% were satisfied with the effect of their medicines, but 94% would be willing to stop their medication if advised by their doctor. Maintaining independence (46%) and reducing pain (31%) were the most important health outcome priorities reported by the patients; staying alive had the lowest priority (51%). Participants with higher levels of educational attainment had better knowledge and had more concerns about harmful effects. Conclusions Patients are open to deprescribing but would probably not initiate the conversation themselves because they are generally very satisfied with their medicines. Knowledge about their medicines and their indications is poor. If doctors initiate deprescribing, patients are probably willing to follow their advice. Patients' life priorities should be discussed in deprescribing conversations.


Assuntos
Desprescrições , Atitude , Estudos Transversais , Humanos , Percepção , Polimedicação
5.
J Am Geriatr Soc ; 69(10): 2973-2984, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34318929

RESUMO

OBJECTIVE: To compare the effectiveness of single, multiple, and multifactorial interventions to prevent falls and fall-related fractures in community-dwelling older persons. METHODS: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) evaluating the effectiveness of fall prevention interventions in community-dwelling adults aged ≥65 years, from inception until February 27, 2019. Two large RCTs (published in 2020 after the search closed) were included in post hoc analyses. Pairwise meta-analysis and network meta-analysis (NMA) were conducted. RESULTS: NMA including 192 studies revealed that the following single interventions, compared with usual care, were associated with reductions in number of fallers: exercise (risk ratio [RR] 0.83; 95% confidence interval [CI] 0.77-0.89) and quality improvement strategies (e.g., patient education) (RR 0.90; 95% CI 0.83-0.98). Exercise as a single intervention was associated with a reduction in falls rate (RR 0.79; 95% CI 0.73-0.86). Common components of multiple interventions significantly associated with a reduction in number of fallers and falls rate were exercise, assistive technology, environmental assessment and modifications, quality improvement strategies, and basic falls risk assessment (e.g., medication review). Multifactorial interventions were associated with a reduction in falls rate (RR 0.87; 95% CI 0.80-0.95), but not with a reduction in number of fallers (RR 0.95; 95% CI 0.89-1.01). The following single interventions, compared with usual care, were associated with reductions in number of fall-related fractures: basic falls risk assessment (RR 0.60; 95% CI 0.39-0.94) and exercise (RR 0.62; 95% CI 0.42-0.90). CONCLUSIONS: In keeping with Tricco et al. (2017), several single and multiple fall prevention interventions are associated with fewer falls. In addition to Tricco, we observe a benefit at the NMA-level of some single interventions on preventing fall-related fractures.

6.
BMJ ; 374: n1585, 2021 07 13.
Artigo em Inglês | MEDLINE | ID: mdl-34257088

RESUMO

OBJECTIVE: To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital. DESIGN: Cluster randomised controlled trial. SETTING: 110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors. PARTICIPANTS: 2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term). INTERVENTION: Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person's prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing. MAIN OUTCOME MEASURE: Primary outcome was first drug related hospital admission within 12 months. RESULTS: 2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths). CONCLUSIONS: Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02986425.


Assuntos
Hospitalização/estatística & dados numéricos , Prescrição Inadequada/prevenção & controle , Multimorbidade , Polimedicação , Acidentes por Quedas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Análise por Conglomerados , Europa (Continente) , Humanos , Prescrição Inadequada/efeitos adversos
7.
J Am Geriatr Soc ; 69(6): 1646-1658, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33576506

RESUMO

OBJECTIVE: To assess the efficacy of medication review as an isolated intervention and with several co-interventions for preventing hospital readmissions in older adults. METHODS: Ovid MEDLINE, Embase, The Cochrane Central Register of Controlled Trials and CINAHL were searched for randomized controlled trials evaluating the effectiveness of medication review interventions with or without co-interventions to prevent hospital readmissions in hospitalized or recently discharged adults aged ≥65, until September 13, 2019. Included outcomes were "at least one all-cause hospital readmission within 30 days and at any time after discharge from the index admission." RESULTS: Twenty-five studies met the inclusion criteria. Of these, 11 studies (7,318 participants) contributed to the network meta-analysis (NMA) on all-cause hospital readmission within 30 days. Medication review in combination with (a) medication reconciliation and patient education (risk ratio (RR) 0.45; 95% confidence interval (CI) 0.26-0.80) and (b) medication reconciliation, patient education, professional education and transitional care (RR 0.64; 95% CI 0.49-0.84) were associated with a lower risk of all-cause hospital readmission compared to usual care. Medication review in isolation did not significantly influence hospital readmissions (RR 1.06; 95% CI 0.45-2.51). The NMA on all-cause hospital readmission at any time included 24 studies (11,677 participants). Medication review combined with medication reconciliation, patient education, professional education and transitional care resulted in a reduction of hospital readmissions (RR 0.82; 95% CI 0.74-0.91) compared to usual care. The quality of the studies included in this systematic review raised some concerns, mainly regarding allocation concealment, blinding and contamination. CONCLUSION: Medication review in combination with medication reconciliation, patient education, professional education and transitional care, was associated with a lower risk of hospital readmissions compared to usual care. An effect of medication review without co-interventions was not demonstrated. Trials of higher quality are needed in this field.


Assuntos
Hospitalização , Reconciliação de Medicamentos , Readmissão do Paciente/estatística & dados numéricos , Cuidado Transicional , Idoso , Humanos , Metanálise em Rede
9.
Eur J Clin Pharmacol ; 77(1): 1-12, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32770278

RESUMO

BACKGROUND: Frailty and adverse drug effects are linked in the fact that polypharmacy is correlated with the severity of frailty; however, a causal relation has not been proven in older people with clinically manifest frailty. METHODS: A literature search was performed in Medline to detect prospective randomized controlled trials (RCTs) testing the effects of pharmacological interventions or medication optimization in older frail adults on comprehensive frailty scores or partial aspects of frailty that were published from January 1998 to October 2019. RESULTS: Twenty-five studies were identified, 4 on comprehensive frailty scores and 21 on aspects of frailty. Two trials on comprehensive frailty scores showed positive results on frailty although the contribution of medication review in a multidimensional approach was unclear. In the studies on aspects related to frailty, ten individual drug interventions showed improvement in physical performance, muscle strength or body composition utilizing alfacalcidol, teriparatide, piroxicam, testosterone, recombinant human chorionic gonadotropin, or capromorelin. There were no studies examining negative effects of drugs on frailty. CONCLUSION: So far, data on a causal relationship between drugs and frailty are inconclusive or related to single-drug interventions on partial aspects of frailty. There is a clear need for RCTs on this topic that should be based on a comprehensive, internationally consistent and thus reproducible concept of frailty assessment.

10.
Age Ageing ; 50(4): 1189-1199, 2021 06 28.
Artigo em Inglês | MEDLINE | ID: mdl-33349863

RESUMO

BACKGROUND: Healthcare professionals are often reluctant to deprescribe fall-risk-increasing drugs (FRIDs). Lack of knowledge and skills form a significant barrier and furthermore, there is no consensus on which medications are considered as FRIDs despite several systematic reviews. To support clinicians in the management of FRIDs and to facilitate the deprescribing process, STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) and a deprescribing tool were developed by a European expert group. METHODS: STOPPFall was created by two facilitators based on evidence from recent meta-analyses and national fall prevention guidelines in Europe. Twenty-four panellists chose their level of agreement on a Likert scale with the items in the STOPPFall in three Delphi panel rounds. A threshold of 70% was selected for consensus a priori. The panellists were asked whether some agents are more fall-risk-increasing than others within the same pharmacological class. In an additional questionnaire, panellists were asked in which cases deprescribing of FRIDs should be considered and how it should be performed. RESULTS: The panellists agreed on 14 medication classes to be included in the STOPPFall. They were mostly psychotropic medications. The panellists indicated 18 differences between pharmacological subclasses with regard to fall-risk-increasing properties. Practical deprescribing guidance was developed for STOPPFall medication classes. CONCLUSION: STOPPFall was created using an expert Delphi consensus process and combined with a practical deprescribing tool designed to optimise medication review. The effectiveness of these tools in falls prevention should be further evaluated in intervention studies.


Assuntos
Acidentes por Quedas , Preparações Farmacêuticas , Acidentes por Quedas/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Técnica Delfos , Europa (Continente) , Humanos , Prescrições
11.
Health Qual Life Outcomes ; 18(1): 317, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32993637

RESUMO

BACKGROUND: The EQ-5D-3L and EQ-5D-5L are two generic health-related quality of life measures, which may be used in clinical and health economic research. They measure impairment in 5 aspects of health: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The aim of this study was to assess the performance of the EQ-5D-3L and EQ-5D-5L in measuring the self-reported health status of older patients with substantial multimorbidity and associated polypharmacy. METHODS: Between 2017 and 2019, we administered EQ-5D-3L and EQ-5D-5L to a subset of patients participating in the OPERAM trial at 6 months and 12 months after enrolment. The OPERAM trial is a two-arm multinational cluster randomised controlled trial of structured medication review assisted by a software-based decision support system versus usual pharmaceutical care, for older people (aged ≥ 70 years) with multimorbidity and polypharmacy. In the psychometric analyses, we only included participants who completed the measures in full at 6 and 12 months. We assessed whether responses to the measures were consistent by assessing the proportion of EQ-5D-5L responses, which were 2 or more levels away from that person's EQ-5D-3L response. We also compared the measures in terms of informativity, and discriminant validity and responsiveness relative to the Barthel Index, which measures independence in activities of daily living. RESULTS: 224 patients (mean age of 77 years; 56% male) were included in the psychometric analyses. Ceiling effects reported with the EQ-5D-5L (22%) were lower than with the EQ-5D-3L (29%). For the mobility item, the EQ-5D-5L demonstrated better informativity (Shannon's evenness index score of 0.86) than the EQ-5D-3L (Shannon's evenness index score of 0.69). Both the 3L and 5L versions of EQ-5D demonstrated good performance in terms of discriminant validity, i.e. (out of all items of the EQ-5D-3L and EQ-5D-5L, the pain/discomfort and anxiety/depression items had the weakest correlation with the Barthel Index. Both the 3L and 5L versions of EQ-5D demonstrated good responsiveness to changes in the Barthel Index. CONCLUSION: Both EQ-5D-3L and EQ-5D-5L demonstrated validity and responsiveness when administered to older adults with substantial multimorbidity and polypharmacy who were able to complete the measures.


Assuntos
Atividades Cotidianas/psicologia , Multimorbidade , Polimedicação , Qualidade de Vida , Inquéritos e Questionários/normas , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Psicometria/instrumentação , Reprodutibilidade dos Testes
12.
Eur J Intern Med ; 78: 121-126, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32487370

RESUMO

BACKGROUND: Anticholinergic drugs may increase the risk of delirium in non-critically ill patients, but it is unclear whether exposure to these drugs is also a risk factor for Intensive Care Unit (ICU) delirium. In this study the hypothesis was tested that anticholinergic drug exposure at ICU admission increases the risk to develop delirium during ICU stay, particularly in patients with advanced age and severe sepsis. METHODS: A prospective cohort study was performed in the mixed 32-bed medical-surgical ICU of the University Medical Center Utrecht, the Netherlands in the period from January 2011 till June 2013. Included were nonneurological patients that were consecutively admitted for more than 24 hours. The presence of delirium was evaluated each day using a validated algorithm based on the Confusion Assessment Method for the ICU (CAM-ICU), the initiation of delirium treatment as well as chart review by researchers. Anticholinergic drug exposure at ICU admission was assessed using the Anticholinergic Drug Scale (ADS). To evaluate the association between anticholinergic drug exposure at ICU admission and the risk of developing delirium, we performed multivariable competing risk Cox proportional hazard analysis corrected for confounding factors. RESULTS: Approximately half (47%, n=513) of the 1090 included patients developed delirium during ICU admission. The absolute risk for delirium development increased with more anticholinergic drug exposure: 42% in patients with ADS score=0, 49% in patients with ADS score=1, and 53% in patients with ADS higher than 1. Taking competing events (death and discharge) and potential confounding factors into account, the subdistribution hazard ratio (SHR) was 1.13 (95% CI: 0.91-1.40) for ADS score=1 point and 1.35 (95% CI: 1.09-1.68) for ADS ≥2 compared with an ADS score=0 (no anticholinergic drug exposure). The effect was strongest during the first days of ICU admittance and was strongest in patients above 65 year without severe sepsis and/or septic shock (SHR 2.15, 95% CI 1.43-3.25). CONCLUSIONS: Anticholinergic drug exposure at ICU admission increases the risk of delirium in critically ill patients. This effect was most pronounced in patients older than 65 years without severe sepsis and/or septic shock, and declining over time.


Assuntos
Delírio , Preparações Farmacêuticas , Antagonistas Colinérgicos/efeitos adversos , Estado Terminal , Delírio/induzido quimicamente , Delírio/epidemiologia , Humanos , Unidades de Terapia Intensiva , Países Baixos/epidemiologia , Estudos Prospectivos
13.
Br J Clin Pharmacol ; 86(10): 1946-1957, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32473057

RESUMO

AIMS: Medication safety requires urgent attention in hospital pharmacy. This study evaluated the medication-related problems/errors as reported to the Dutch medication incident registry and disseminated for information to pharmacists. Through analysis by an expert panel we aimed to better understand which problems could have been mitigated by the drug product design. Additionally, the (wider) implications of the problems for current hospital/clinical practice were discussed. METHODS: Items were extracted from the public Portal for Patient Safety. Items were included if relevant for older people and connected with the drug product design and excluded if they should reasonably have been intercepted by compliance to routine controls or well-known professional standards in pharmaceutical care. To explore any underreporting of well-known incidents, it was investigated if different medication-related problems could be observed in a regional hospital practise over a 1-month period. For 6 included items (cases), the implications for hospital/clinical practise were discussed in an expert panel. RESULTS: In total, 307 items were identified in the Portal for Patient Safety; all but 14 were excluded. Six cases were added from daily hospital practice. These 20 cases commonly related to confusing product characteristics, packaging issues such as the lack of a single unit package for an oncolytic product, or incorrect or incomplete user instructions. CONCLUSION: Medication registries provide important opportunities to evaluate real-world medication-related problems. However, underreporting of well-known problems should be considered. The product design can be used as an (additional) risk mitigation measure to support medication safety in hospital practice.

14.
BMC Health Serv Res ; 20(1): 220, 2020 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-32183810

RESUMO

BACKGROUND: Several approaches to medication optimisation by identifying drug-related problems in older people have been described. Although some interventions have shown reductions in drug-related problems (DRPs), evidence supporting the effectiveness of medication reviews on clinical and economic outcomes is lacking. Application of the STOPP/START (version 2) explicit screening tool for inappropriate prescribing has decreased inappropriate prescribing and significantly reduced adverse drug reactions (ADRs) and associated healthcare costs in older patients with multi-morbidity and polypharmacy. Therefore, application of STOPP/START criteria during a medication review is likely to be beneficial. Incorporation of explicit screening tools into clinical decision support systems (CDSS) has gained traction as a means to improve both quality and efficiency in the rather time-consuming medication review process. Although CDSS can generate more potential inappropriate medication recommendations, some of these have been shown to be less clinically relevant, resulting in alert fatigue. Moreover, explicit tools such as STOPP/START do not cover all relevant DRPs on an individual patient level. The OPERAM study aims to assess the impact of a structured drug review on the quality of pharmacotherapy in older people with multi-morbidity and polypharmacy. The aim of this paper is to describe the structured, multi-component intervention of the OPERAM trial and compare it with the approach in the comparator arm. METHOD: This paper describes a multi-component intervention, integrating interventions that have demonstrated effectiveness in defining DRPs. The intervention involves a structured history-taking of medication (SHiM), a medication review according to the systemic tool to reduce inappropriate prescribing (STRIP) method, assisted by a clinical decision support system (STRIP Assistant, STRIPA) with integrated STOPP/START criteria (version 2), followed by shared decision-making with both patient and attending physician. The developed method integrates patient input, patient data, involvement from other healthcare professionals and CDSS-assistance into one structured intervention. DISCUSSION: The clinical and economical effectiveness of this experimental intervention will be evaluated in a cohort of hospitalised, older patients with multi-morbidity and polypharmacy in the multicentre, randomized controlled OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multi-morbid elderly), which will be completed in the last quarter of 2019. TRIAL REGISTRATION: Universal Trial Number: U1111-1181-9400 Clinicaltrials.gov: NCT02986425, Registered 08 December 2016. FOPH (Swiss national portal): SNCTP000002183. Netherlands Trial Register: NTR6012 (07-10-2016).


Assuntos
Sistemas de Apoio a Decisões Clínicas , Hospitalização , Prescrição Inadequada/prevenção & controle , Reconciliação de Medicamentos/métodos , Lista de Medicamentos Potencialmente Inapropriados , Idoso , Doença Crônica/tratamento farmacológico , Estudos de Coortes , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Humanos , Multimorbidade , Polimedicação , Projetos de Pesquisa
15.
BMJ Open ; 10(2): e033721, 2020 02 18.
Artigo em Inglês | MEDLINE | ID: mdl-32075833

RESUMO

OBJECTIVES: Appropriate prescribing in older people continues to be challenging. Studies still report a high prevalence of inappropriate prescribing in older people. To reduce the problem of underprescribing and overprescribing in this population, explicit drug optimisation tools like Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) have been developed. The aim of this study was to evaluate the clinical applicability of STOPP/START criteria in daily patient care by assessing the clarity of singular criteria. DESIGN: Quality appraisal study. METHODS: For each of the 114 STOPP/START criteria V.2, elements describing the action (what/how to do), condition (when to do) and explanation (why to do) were identified. Next, the clarity of these three elements was quantified on a 7-point Likert scale using tools provided by the Appraisal of Guidelines for Research and Evaluation (AGREE) Consortium. PRIMARY AND SECONDARY OUTCOMES: The primary outcome measure was the clarity rating per element, categorised into high (>67.7%), moderate (33.3%-67.7%) or low (<33.3%). Secondary, factors that positively or negatively affected clarity most were identified. Additionally, the nature of the conditions was further classified into five descriptive components: disease, sign, symptom, laboratory finding and medication. RESULTS: STOPP recommendations had an average clarity rating of 64%, 60% and 69% for actions, conditions and explanations, respectively. The average clarity rating in START recommendations was 60% and 57% for actions and conditions, respectively. There were no statements present to substantiate the prescription of potential omissions for the 34 START criteria. CONCLUSIONS: Our results show that the clarity of the STOPP/START criteria can be improved. For future development of explicit drug optimisation tools, such as STOPP/START, our findings identified facilitators (high clarity) and barriers (low clarity) that can be used to improve the clarity of clinical practice guidelines on a language level and therefore enhance clinical applicability.


Assuntos
Comunicação , Prescrições de Medicamentos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Prescrição Inadequada/prevenção & controle , Lista de Medicamentos Potencialmente Inapropriados , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Idoso , Idoso de 80 Anos ou mais , Atenção à Saúde , Humanos , Idioma , Programas de Rastreamento , Multimorbidade , Segurança do Paciente , Polimedicação , Fatores de Risco , Incerteza
16.
J Am Geriatr Soc ; 68(2): 329-336, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31647578

RESUMO

OBJECTIVE: To explore the effect of initiating statins for secondary prevention after a first myocardial infarction (MI) in patients aged 80 years and older. DESIGN: Retrospective cohort study. SETTING: Clinical Practice Research Datalink (1999-2016). PARTICIPANTS: Patients, aged 65 years and older, hospitalized after a first MI without a statin prescription in the year before hospitalization. The age group of 65 to 80 years was included to compare our results to current evidence. MEASUREMENTS: The primary outcome was a composite of recurrent MI, stroke, and cardiovascular mortality; and the secondary outcome was all-cause mortality. A time-varying Cox model was used to account for statin prescription over time. We compared at least 2 years of statin prescription time with untreated and less than 2 years of prescription time. Analyses were adjusted for potential confounders. The number needed to treat (NNT) was calculated based on the adjusted hazard ratios (HRs) and corrected for deaths during the first 2 years of follow-up. RESULTS: A total of 9020 patients were included. Among the 3900 patients aged 80 years and older, 2 years of statin prescriptions resulted in a lower risk of the composite outcome (adjusted HR = 0.81; 95% confidence interval [CI] = 0.66-0.99) and of all-cause mortality (adjusted HR = 0.84; 95% CI = 0.73-0.97). During 4.5 years of median follow-up, the NNT for prevention of the primary outcome was 59; and for mortality, the NNT was 36. Correcting for 36.2% deaths during the first 2 years increased the NNT on the primary outcome to 93 and to 61 on all-cause mortality. CONCLUSION: Our data support statin initiation after a first MI in patients aged 80 years and older if continued for at least 2 years. Especially in patients with a low risk of 2-year mortality, statins should be considered. J Am Geriatr Soc 68:329-336, 2020.


Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Prevenção Secundária , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Bases de Dados Factuais , Feminino , Humanos , Masculino , Infarto do Miocárdio/mortalidade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Acidente Vascular Cerebral/prevenção & controle
17.
BMJ Open ; 9(6): e026769, 2019 06 03.
Artigo em Inglês | MEDLINE | ID: mdl-31164366

RESUMO

INTRODUCTION: Multimorbidity and polypharmacy are important risk factors for drug-related hospital admissions (DRAs). DRAs are often linked to prescribing problems (overprescribing and underprescribing), as well as non-adherence with drug regimens for different reasons. In this trial, we aim to assess whether a structured medication review compared with standard care can reduce DRAs in multimorbid older patients with polypharmacy. METHODS AND ANALYSIS: OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people is a European multicentre, cluster randomised, controlled trial. Hospitalised patients ≥70 years with ≥3 chronic medical conditions and concurrent use of ≥5 chronic medications are included in the four participating study centres of Bern (Switzerland), Utrecht (The Netherlands), Brussels (Belgium) and Cork (Ireland). Patients treated by the same prescribing physician constitute a cluster, and clusters are randomised 1:1 to either standard care or Systematic Tool to Reduce Inappropriate Prescribing (STRIP) intervention with the help of a clinical decision support system, the STRIP Assistant. STRIP is a structured method performing customised medication reviews, based on Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment criteria to detect potentially inappropriate prescribing. The primary endpoint is any DRA where the main reason or a contributory reason for the patient's admission is caused by overtreatment or undertreatment, and/or inappropriate treatment. Secondary endpoints include number of any hospitalisations, all-cause mortality, number of falls, quality of life, degree of polypharmacy, activities of daily living, patient's drug compliance, the number of significant drug-drug interactions, drug overuse and underuse and potentially inappropriate medication. ETHICS AND DISSEMINATION: The local Ethics Committees in Switzerland, Ireland, The Netherlands and Belgium approved this trial protocol. We will publish the results of this trial in a peer-reviewed journal. MAIN FUNDING: European Union's Horizon 2020 programme. TRIAL REGISTRATION NUMBER: NCT02986425 , SNCTP000002183 , NTR6012, U1111-1181-9400.


Assuntos
Doença Crônica/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Geriatria , Hospitalização/estatística & dados numéricos , Prescrição Inadequada/prevenção & controle , Lista de Medicamentos Potencialmente Inapropriados/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/tratamento farmacológico , Análise por Conglomerados , Sistemas de Apoio a Decisões Clínicas , Feminino , Humanos , Masculino , Multimorbidade , Polimedicação , Qualidade de Vida
18.
Br J Clin Pharmacol ; 85(9): 1974-1983, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31108564

RESUMO

AIMS: The Systematic Tool to Reduce Inappropriate Prescribing is a method to assess patient's medication and has been incorporated into a clinical decision support system: STRIP Assistant. Our aim was to evaluate the effect of recommendations generated using STRIP Assistant on appropriate prescribing and mortality in a preoperative setting. METHODS: This cluster-randomized controlled trial was carried out at the preoperative geriatric outpatient clinic. Residents who performed a comprehensive geriatric assessment were randomized to the control group and intervention group in a 1:1 ratio. Visiting patients aged 70 years or older on 5 or more medications were included. INTERVENTION: prescribing recommendations were generated by a physician using STRIP Assistant and given to the resident. Control group residents performed a medication review according to usual care. PRIMARY OUTCOME: number of medication changes made because of potential prescribing omissions (PPOs), potentially inappropriate medications (PIMs), and suboptimal dosages according to the prescribing recommendations. Secondary outcome: 3-month postoperative mortality. RESULTS: 65 intervention and 59 control patients were included, attended by 34 residents. Significantly more medication changes because of PPOs and PIMs were made in the intervention group than in the control group (PPOs 26.2% vs 3.4%, odds ratio 0.04 [95% confidence interval 0.003-0.46] P < .05; PIMS 46.2% vs 15.3% odds ratio 0.14 [95% confidence interval 0.07-0.57] P < .005). There were no differences in dose adjustments or in postoperative mortality. CONCLUSION: Prescribing recommendations generated with the help of STRIP Assistant improved appropriate prescribing in a preoperative geriatric outpatient clinic but did not affect postoperative mortality.


Assuntos
Sistemas de Apoio a Decisões Clínicas/organização & administração , Serviços de Saúde para Idosos/organização & administração , Prescrição Inadequada/prevenção & controle , Ambulatório Hospitalar/organização & administração , Complicações Pós-Operatórias/mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Consenso , Relação Dose-Resposta a Droga , Prescrições de Medicamentos/normas , Feminino , Implementação de Plano de Saúde , Serviços de Saúde para Idosos/normas , Mortalidade Hospitalar , Humanos , Masculino , Países Baixos , Ambulatório Hospitalar/normas , Complicações Pós-Operatórias/etiologia , Lista de Medicamentos Potencialmente Inapropriados/normas , Guias de Prática Clínica como Assunto , Período Pré-Operatório , Avaliação de Programas e Projetos de Saúde , Procedimentos Cirúrgicos Operatórios/efeitos adversos
19.
Maturitas ; 124: 43-47, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31097178

RESUMO

Achieving appropriate medication is a multidimensional process. Current research on polypharmacy mainly focuses on drug appropriateness, but little is devoted to what determines the ongoing challenge. The authors, with their diverse clinical, pharmaceutical and regulatory backgrounds, offer a narrative review on the causes of inappropriate polypharmacy and how to avoid it. Inappropriate polypharmacy may stem from the systematic exclusion of frail older patients from landmark randomised controlled trials, which has prevented the accurate establishment of the clinical benefits of a drug for that ever-growing group of patients. Nonetheless, what may determine the usefulness of a drug in a specific patient cohort is its design. Patient-centric drug product development must, therefore, account for older people's characteristics, so that drugs are better formulated from their inception. This novel drug development process has significant implications for industry and requires adequate regulation. Clinicians must understand and be part of drug development. Explicit criteria such as STOPP/START provide guidance on identifying opportunities and circumstances to review medication but achieving appropriateness is far more complicated. New healthcare technology may pave the way to better-tailored interventions at a healthcare system level, but patient and advocate voices, as well as communication and continuity of care, must remain at the core. In conclusion, inappropriate polypharmacy results from the combination of multiple factors. Achieving appropriate medication for older adults requires merging different disciplines and a focus on patients' needs and expectations.


Assuntos
Prescrição Inadequada , Polimedicação , Idoso , Idoso de 80 Anos ou mais , Comunicação , Técnicas de Apoio para a Decisão , Desenvolvimento de Medicamentos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Humanos , Prescrição Inadequada/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto
20.
Eur Geriatr Med ; 10(1): 9-36, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32720270

RESUMO

PURPOSE: To investigate: (1) the cross-sectional association between polypharmacy, hyperpolypharmacy and presence of prefrailty or frailty; (2) the risk of incident prefrailty or frailty in persons with polypharmacy, and vice versa. METHODS: A systematic review and meta-analysis was performed according to PRISMA guidelines. We searched PubMed, Web of Science, and Embase from 01/01/1998 to 5/2/2018. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting. Homogeneity was assessed with the I2 statistic and publication bias with Egger's and Begg's tests. RESULTS: Thirty-seven studies were included. The pooled proportion of polypharmacy in persons with prefrailty and frailty was 47% (95% CI 33-61) and 59% (95% CI 42-76), respectively. Increased odds ratio of polypharmacy were seen for prefrail (pooled OR = 1.52; 95% CI 1.32-1.79) and frail persons (pooled OR = 2.62, 95% CI 1.81-3.79). Hyperpolypharmacy was also increased in prefrail (OR = 1.95; 95% CI 1.41-2.70) and frail (OR = 6.57; 95% CI 9.57-10.48) persons compared to robust persons. Only seven longitudinal studies reported data on the risk of either incident prefrailty or frailty in persons with baseline polypharmacy. A significant higher odds of developing prefrailty was found in robust persons with polypharmacy (pooled OR = 1.30; 95% CI 1.12-1.51). We found no papers investigating polypharmacy incidence in persons with prefrailty/frailty. CONCLUSIONS: Polypharmacy is common in prefrail and frail persons, and these individuals are also more likely to be on extreme drug regimens, i.e. hyperpolypharmacy, than robust older persons. More research is needed to investigate the causal relationship between polypharmacy and frailty syndromes, thereby identifying ways to jointly reduce drug burden and prefrailty/frailty in these individuals. PROSPERO REGISTRATION NUMBER: CRD42018104756.

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