Appropriateness of Antiplatelets and Anticoagulants Among Older Adults Experiencing Falls.

INTRODUCTION: Antithrombotic (AT) use among geriatric population (=65 years) has been associated with worse outcomes after traumatic brain injury (TBI). Previous studies have found that use of AT outside of established guideline is widespread in the general population and TBI patients. METHODS: We retrospective reviewed charts of geriatric TBI patients with preinjury AT use from 2016 and 2023. Patient demographics, AT indications/types, and post-injury outcomes were extracted. The appropriateness of AT use was determined using established clinical guidelines. RESULTS: Our cohort consisted of 145 patients (43.4% females, 56.6% males; mean age 79±7 years). Fall was the most common mechanism of injury (88.3%). 84.8% patients were classified to have mild TBI (GCS 13-15) on initial presentation. Two most common indications for AT included atrial fibrillation (41.1%) and venous thromboembolism (VTE) (20.7%). 45.5% of patients were on an anticoagulant, 41.4% on an antiplatelets, and 13.1% were on both. Prescribed AT agents included warfarin (27.6%), direct oral anticoagulants (30.3%), aspirin (35.2%), and clopidogrel (18.6%). Following clinical guidelines, 16.6% of the patients were deemed inappropriately on AT therapy. On multivariate analysis, VTE indication (OR 3.71, 95% CI 1.33-10.33, p=0.012) and aspirin use (OR 3.31, 95% CI 3.314-27.4, p=<0.001) were associated with inappropriate AT use. Outcomes (length of stay, disposition, and 30-day mortality) following TBI were not significantly different between patients who were appropriately or inappropriately on AT. CONCLUSIONS: Sixteen percent of geriatric TBI patients were observed to be inappropriately consuming AT medications. The most common diagnosis was history of VTE. Aspirin was the most common medication inappropriately used. While the inappropriate utilization of ATs did not result in worsened outcomes in our cohort, further consideration of the implications of polypharmacy in the geriatric population is warranted.

Antithrombotic (AT) therapy is frequently prescribed to patients for stroke prevention, atrial fibrillation, or other purposes, but it is a potential risk factor for chronic subdural hematoma (cSDH) development and growth. Premorbid AT use is common among patients who present with cSDH requiring treatment. The authors assessed the prevalence of AT use outside established clinical guidelines among patients who underwent cSDH treatment at three academic hospitals. This was a multicenter retrospective review of patients with cSDH who underwent surgical intervention and/or middle meningeal artery embolization (MMAE) between 2019 and 2024. Demographic data, presenting clinical and radiographic findings, and AT indications and types were extracted. Appropriateness of AT use was assessed according to clinical guidelines. The cohort comprised 148 patients (77% male; mean age 74.96 ± 10.37 years) who underwent evacuation surgery alone (66.9%), MMAE (18.9%), or surgery with MMAE (14.2%). At presentation, the mean maximum hematoma thickness was 18.83 ± 6.5 mm, and 87.8% of patients had a midline shift. The most common indications for AT use were atrial fibrillation (27.0%) and coronary artery disease (24.3%). Antiplatelet monotherapy had been prescribed premorbidly to 58.1% of patients, anticoagulation monotherapy to 28.4%, and both to 13.5%. AT agents included aspirin (47.3%), direct oral anticoagulants (20.9%), warfarin (18.9%), dual antiplatelet therapy (18.2%), clopidogrel (7.4%), and therapeutic low-molecular-weight heparin (3.4%). Per clinical guidelines, 31.1% of patients were found to be inappropriately on AT therapy. Specific AT agents were not found to be associated with inappropriate AT consumption. Multivariable analysis identified cardiac stents (OR 3.95, 95% CI 1.05-14.88; p = 0.042) and primary and secondary stroke prevention (OR 10.59, 95% CI 3.20-35.09; p = 0.001) as indications associated with inappropriate AT use. Conversely, atrial fibrillation was associated with a lower likelihood of inappropriate AT use (OR 0.17, 95% CI 0.03-0.85; p = 0.031). In this study, nearly one-third of patients requiring treatment for cSDH were found to be inappropriately using AT medications, with primary and secondary stroke prevention and cardiac stents identified as independent predictors of such use. Greater vigilance among care teams is essential to address the burden of inappropriate AT use and potentially prevent the development of cSDH.

Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial

INTRODUCTION: Antithrombotic (AT) therapy is common among chronic subdural hematoma (cSDH) patients, potentially representing a risk factor for cSDH development and progression. METHODS: A multicenter retrospective review of cSDH patients who underwent surgical intervention and/or MMAe between 2019 and 2023 was conducted. Demographic data, presenting clinical/radiographic findings, AT indications/types, and post-treatment outcomes were extracted. Appropriateness of AT use was assessed according to clinical guidelines. RESULTS: A cohort of 224 (26.8% female, 73.2% male; mean age 69.9 ± 12 years) underwent surgery alone (81.3%) or surgery plus MMAe (18.8%). 38.4% were on AT therapy, with 30.2% on anticoagulants alone, 43.0% on antiplatelets alone, and 26.7% on both. Agents included warfarin (19.8%), direct oral anticoagulants (24.4%), low molecular weight heparin (12.8%), aspirin (51.2%), clopidogrel (8.1%), and dual antiplatelet therapy (DAPT; 10.5%). Indication for AT included atrial fibrillation (26.7%), venous thromboembolism (25.6%), coronary artery disease (24.4%), intra-arterial stents (10.5%), secondary stroke prevention (10.5%), and others (2.3%). After referencing clinical guidelines, 16.3% of patients were deemed inappropriately on AT therapy. On multivariate analysis, secondary stroke prevention (OR 5.62, 95% CI 1.26-25.30, p=0.024), and DAPT (OR 7.3, 95% CI 1.40-37.95 p=0.018) were associated with inappropriate AT use. No differences in hospital length of stay, 30-day mortality, readmission, or reoperation for hematoma recurrence between AT patients and those not on AT were observed. However, patients not on AT had higher odds of >50% reduction in target hematoma at time of discharge (OR 1.95, 95% CI 1.12-3.43, p=0.019). CONCLUSIONS: A significant number of cSDH patients were inappropriately using AT medications, with secondary stroke prevention and DAPT regimen being independent predictors for such use. Patients not on AT therapy had better radiographic outcomes at discharge, emphasizing the importance of eliminating unnecessary AT use as a potential means of primary prevention of cSDH.

Preinjury antithrombotic (AT) use is associated with worse outcomes for geriatric (65 years or older) patients with traumatic brain injury (TBI). Previous studies have found that use of AT outside established guidelines is widespread in TBI patients. In this single-center retrospective cross-sectional study, we examined inappropriate AT use among geriatric patients presenting with traumatic intracranial hemorrhage. We reviewed records of patients 65 years or older with preinjury AT use who presented to a Level 1 trauma center with traumatic intracranial hemorrhage between 2016 and 2023. Patient demographics and AT indications/types were extracted. Appropriateness of AT use was determined using established guidelines. The cohort comprised 207 patients (56.5% male; median age, 77 years). Fall was the most common mechanism of injury (87.9%). At initial presentation, 87.0% of patients had mild TBI (Glasgow Coma Scale scores 13-15). The two most common indications for AT use were atrial fibrillation (41.5%) and venous thromboembolism (14.5%). Anticoagulation therapy was used by 51.7% of patients, antiplatelet therapy by 40.1%, and both by 8.2%. Prescribed AT agents included warfarin (23.2%), direct oral anticoagulants (36.2%), aspirin (32.4%), and clopidogrel (15.0%). Per clinical guidelines, 31 patients (15.0%) were determined to be inappropriately on AT therapy. On multivariable analysis, venous thromboembolism (odds ratio [OR], 5.32; 95% confidence interval [CI], 1.80-15.71; p = 0.002) and arterial stent (OR, 4.69; 95% CI, 1.53-14.37; p = 0.007) were associated with inappropriate AT use; aspirin was the most common inappropriately prescribed AT (OR, 3.59; 95% CI, 1.45-8.91; p = 0.006). Overall, 15% of geriatric TBI patients with preinjury AT use were prescribed this therapy outside of current guidelines. Trauma providers should remain vigilant in identifying such patients and collaborate across multidisciplinary teams to implement interventions that minimize inappropriate AT use. Prognostic and Epidemiological; Level IV.

BackgroundInappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding....

BACKGROUND The inappropriate use of multiple medications known as polypharmacy is a growing concern for older populations with comorbid conditions in India. Polypharmacy can lead to serious adverse health outcomes, increased health care costs, and reduced quality of life. Screening tools such as the Medication Appropriateness Index (MAI) and Screening Tool for Older Persons’ Prescriptions (STOPP) or Screening Tool to Alert to Right Treatment (START) criteria can help identify potentially inappropriate medications, and interventions such as medication review clinics and prescribing audits can help improve the appropriateness. A collaborative medication review (CMR) involving a team approach is important to ensure that patients receive the best possible care. OBJECTIVE The primary objective is to assess the feasibility of implementation of interdepartmental CMR to reduce potentially inappropriate medications in hospitalized older adults. The secondary objectives are to (1) explore the facilitators and barriers in this implementation from the health care providers’ perspective, (2) determine the costs involved in the implementation from a health system perspective, and (3) analyze the efficacy of interdepartmental CMR by using MAI, postdischarge adverse events, and number of medication-related admissions. METHODS This study consists of 5 phases aimed at improving CMR practices in India. Phase 1 focused on conducting a scoping review of CMR practices. Phase 2 involved creating standard operating procedures to establish a CMR team, delineating roles and responsibilities, and providing training. Phase 3 will evaluate the efficacy of CMR by using standardized tools such as MAI and STOPP/START criteria. Phase 4 assesses the challenges faced in implementing CMR. Finally, phase 5 analyzes the costs related to CMR implementation. This study employs a multicentered mixed methods approach, combining qualitative methods (in-depth interviews and focus group discussions) to explore implementation challenges and quantitative analysis through a quasi-experimental study involving 280 hospitalized older adults. It aims to measure costs and the reduction of potentially inappropriate medications post discharge. RESULTS This study received a grant from the Indian Council of Medical Research–Safe and Rational Use of Medicine Task Force in December 2023. All study preparatory approvals were obtained. Phase 1 and phase 2 were completed by December 2024. Phase 3 is scheduled to finish by June 2025. Phases 4 and 5 are planned for completion by August 2025. Final data analysis and manuscript submission are expected by December 2025. CONCLUSIONS This study can provide insights into the implementation and effectiveness of CMR and help to understand the facilitators and barriers to implementing interdepartmental CMR and the cost incurred in its implementation. Interprofessional teams will collaboratively review and optimize medications for older patients with multimorbidity in India—a strategy expected to enhance care coordination, improve clinical outcomes, and reduce health care costs. CLINICALTRIAL Clinical Trials Registry – India CTRI/2024/06/069220; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=OTgyNDg=&Enc=&userName=

BackgroundThe inappropriate use of multiple medications known as polypharmacy is a growing concern for older populations with comorbid conditions in India. Polypharmacy can lead to serious adverse health outcomes, increased health care costs, and reduced quality of life. Screening tools such as the Medication Appropriateness Index (MAI) and Screening Tool for Older Persons’ Prescriptions (STOPP) or Screening Tool to Alert to Right Treatment (START) criteria can help identify potentially inappropriate medications, and interventions such as medication review clinics and prescribing audits can help improve the appropriateness. A collaborative medication review (CMR) involving a team approach is important to ensure that patients receive the best possible care.ObjectiveThe primary objective is to assess the feasibility of implementation of interdepartmental CMR to reduce potentially inappropriate medications in hospitalized older adults. The secondary objectives are to (1) explore the facilitators and barriers in this implementation from the health care providers’ perspective, (2) determine the costs involved in the implementation from a health system perspective, and (3) analyze the efficacy of interdepartmental CMR by using MAI, postdischarge adverse events, and number of medication-related admissions.MethodsThis study consists of 5 phases aimed at improving CMR practices in India. Phase 1 focused on conducting a scoping review of CMR practices. Phase 2 involved creating standard operating procedures to establish a CMR team, delineating roles and responsibilities, and providing training. Phase 3 will evaluate the efficacy of CMR by using standardized tools such as MAI and STOPP/START criteria. Phase 4 assesses the challenges faced in implementing CMR. Finally, phase 5 analyzes the costs related to CMR implementation. This study employs a multicentered mixed methods approach, combining qualitative methods (in-depth interviews and focus group discussions) to explore implementation challenges and quantitative analysis through a quasi-experimental study involving 280 hospitalized older adults. It aims to measure costs and the reduction of potentially inappropriate medications post discharge.ResultsThis study received a grant from the Indian Council of Medical Research–Safe and Rational Use of Medicine Task Force in December 2023. All study preparatory approvals were obtained. Phase 1 and phase 2 were completed by December 2024. Phase 3 is scheduled to finish by June 2025. Phases 4 and 5 are planned for completion by August 2025. Final data analysis and manuscript submission are expected by December 2025.ConclusionsThis study can provide insights into the implementation and effectiveness of CMR and help to understand the facilitators and barriers to implementing interdepartmental CMR and the cost incurred in its implementation. Interprofessional teams will collaboratively review and optimize medications for older patients with multimorbidity in India—a strategy expected to enhance care coordination, improve clinical outcomes, and reduce health care costs.Trial RegistrationClinical Trials Registry – India CTRI/2024/06/069220; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=OTgyNDg=&Enc=&userName=

Musculoskeletal disorders are frequently associated with pain in older adults, and the use of inappropriate analgesics drugs is common. Understanding the patterns and factors of inappropriate analgesic use may help reduce its prevalence among older adults with chronic musculoskeletal pain. This cross-sectional study evaluated 215 older adults aged ≥ 60 years who experienced chronic musculoskeletal pain and used oral medication to relieve pain within the previous 3 months. Participants were recruited through home visits using the community health register in Ban Phru, Hat Yai District, Songkhla Province (Southern Thailand) between July and December 2023. Analgesic use was determined by directly inspecting the drugs that participants were taking within the previous 3 months, regardless of whether they were prescribed or self-purchased. The name, dose, and source of each medication were recorded and cross-checked with the 2023 American Geriatrics Society Beers Criteria to identify potentially inappropriate drugs. This approach enabled differentiation into three patterns of inappropriate analgesic drug use: potentially inappropriate medication use, overtreatment, and undertreatment. Factors associated with the inappropriate use of analgesic drugs were analysed using multivariate logistic regression analysis. Inappropriate analgesic drug use was prevalent in 66.5%. Regarding the prevalence rates by pattern, potentially inappropriate, overtreatment, and undertreatment were prevalent in 71.3%, 24.5%, and 33.6%, respectively. Non-prescribed polypharmaceutical packs (adjusted odds ratio [aOR] [95% confidence interval {CI}] = 11.45 [3.32, 72.15], P < 0.001) and pain interfering with enjoyment of life (aOR [95% CI] = 1.16 [1.04, 1.30], P = 0.007) were significantly associated with inappropriate analgesic drug use. Inappropriate analgesic use was common, affecting 66.5% of community-dwelling older adults with chronic musculoskeletal pain. Non-prescribed polypharmaceutical packs and pain interference were significant predictors of inappropriate use. These findings underscore the influence of inappropriate self-medication, suggesting the need for greater attention from healthcare providers to promote safe and rational analgesic use in this population.

Risk factors for inappropriate ciprofloxacin use in an emergency department

BackgroundFalls, a leading cause of disability and mortality in older adults,1 are associated cognitive impairment and inappropriate medication use.2 We propose a novel construct, “mobility reserve” (MR), which describes an individual’s resilience against mobility decline. We hypothesize that augmenting MR may delay fall‐associated morbidity. Here, we investigate the association between MR and inappropriate medication use among participants with and without preclinical Alzheimer’s disease (pAD) enrolled in a randomized medication therapy management trial.3 MethodsNon‐demented older adults who used ≥1 potentially inappropriate medication4 were recruited for the RCT. The Medication Appropriateness Index was calculated for all medications (MAI) and for potentially inappropriate medications (MAI‐PIM). Participants’ gait speed (cm/s) was measured under normal conditions and while challenged with 1.5mg of scopolamine to unmask vulnerability. The difference in gait speeds was calculated as mobility reserve change score (MRCS). PET amyloid total brain relative standardized uptake values &gt; 1.4 was used to define pAD.5Spearman correlation coefficients (rs) assessed the relationship between medication appropriateness and MRCS.Results36 participants were included in this analysis (mean age 75.0 years [SD 6.0]; 78% female); 10 (27.8%) were classified as pAD. The mean (SD) MAI and MAI‐PIM were 10.3 (5.1) and 5.4 (4.0) respectively, not differing by pAD status (p=0.92 and 0.11 for MAI and MAI‐PIM). The mean (SD) MRCS was ‐0.39 cm/s (9.4) (no difference by pAD status; p=0.84). Among those with pAD, MAI and MAI‐PIM were negatively correlated with MRCS (r = ‐0.53 and ‐0.46 respectively), which was not the case among those without pAD (r = 0.37 and 0.34), though a larger sample size is needed to add confidence to these estimates.ConclusionAmong community‐dwelling non‐demented older adults, more inappropriate medication use was associated with lower mobility reserve among those with pAD. These results support the hypothesized relationship between MR and medication appropriateness. Future studies should further operationalize measures of MR to open a novel intervention pathway for reducing fall‐related morbidity in cognitively at‐risk populations.

To determine the association between inappropriate medication use and self-reported adverse drug effects (ADEs). Prospective cohort study with three annual mailed surveys. Population-based sample of Iowa Medicare beneficiaries. Cohort members (n5626) with established mobility disability and complete pharmacy dispensing records, continuous Medicare eligibility, and survey data. The number of unique drug ingredients dispensed and inappropriate use were assessed for the year before the ADE survey. Inappropriate medication use was defined according to published criteria: contraindicated drugs for elderly people, drug-disease interactions (constructed from linked Medicare claims), drug-drug interactions, and therapeutic duplications. An ADE was defined from the following question: "In the past 12 months, have you experienced an unwanted effect or side effect of a medication?" Of respondents to the ADE survey, 22.0% reported having experienced an ADE in the past year, and 322 (51.4%) received at least one potential inappropriate medication. Factors associated univariately with ADE self-report were number of medications, number of mobility limitations, any inappropriate medication use, and each of the individual domain appropriateness indicators, as well as number of different domains of inappropriate use. The adjusted odds ratio for developing an ADE was 2.14 (95% confidence interval=1.26-3.65) for those with inappropriate use versus no inappropriate use. Efforts to reduce ADEs by reducing medication inappropriateness should be encouraged as a complement to efforts focused on reducing the number of medications prescribed.

Osteoarthritis (OA) is a degenerative arthritis affecting over 30 million Americans most of whom are over 65 years or older. Its clinical management is complicated by several disease- and treatment-specific factors. These include the co-occurrence of cardiovascular and gastrointestinal disorders (CV-GID), the inappropriate use of non-steroidal anti-inflammatory drugs (NSAID) to manage pain, and the risk of certain age-related chronic conditions like Alzheimer’s disease and related dementia (ADRD). Moreover, older adults with OA are at a higher risk of CV-GID, inappropriate NSAID use, and ADRD. Additionally, these factors can also affect one another in both a positive and a negative way. For example, the long-term use of NSAID has been shown to increase the risk for cardiovascular and gastrointestinal disorders. On the other hand, their use has been shown to decrease the risk of ADRD in some studies. NSAID use is disproportionately higher among older adults, so the benefits or risks associated with such use should be taken into account while making treatment decisions. However, there is a gap in our understanding of the clinical and demographic factors that increase the risk of co-occurring CV-GID, inappropriate NSAID use, and ADRD in older adults with OA. This dissertation pursued three related aims to fill this knowledge gap: 1) identify the leading predictors of CV-GID; 2) identify the leading predictors of inappropriate NSAID use; and 3) examine whether duration of NSAID use is a leading predictor of ADRD and how other factors affect this relationship using a combination of machine learning techniques. All three aims used a retrospective, longitudinal, cohort study design using de-identified commercial health insurance insurance claims data from Optum De-identified Clinformatics Data Mart for years 2015 through 2017. OA was identified from these data using a combination of International Classification of Disease – 9th Revision and 10th Revision (ICD-9 and ICD-10) codes. Using a random forest classifier, we identified age, cardiac arrhythmia, and the duration of opioid use to be the top three leading predictors of CV-GID in our study cohort. In the second aim, we found that around 13% of older adults with OA were prescribe NSAIDs not in accordance with their CV and GI risk profile (i.e. inappropriate NSAID use). Using an eXtreme Gradient Boosting classifier and Shapley Additive eXplanations, we found durations of non-selective and selective NSAID use to be the top two predictors of inappropriate NSAID use. Older adults with low CV and high GI or

Background Sleep disorders such as insomnia may occur in old age, potentially leading to z-hypnotic use. However, few studies have explored older adults’ self-reported sleep concerns in relation to z-hypnotic use. We aim to examine this relationship. Methods We conducted a cross-sectional study using a web-based questionnaire to assess sleep disturbances and medication use (z-hypnotics, benzodiazepines, and opioid analgesics) among 5,194 older adults through 21 GPs in southeast Norway. The main outcome, inappropriate z-hypnotic use, was defined as self-reported use for ≥4 weeks at ≥ three times per week. We used descriptive statistics and exploratory logistic regression mixed-effects models for data analysis. Results Among the 687 patients included in the study, 22% (N = 153) reported sleep disturbances. Of these, 84% (N = 575) did not use z-hypnotics, while 16% (N = 112) used z-hypnotics, 63% (N = 71) of these used them inappropriately. (≥4 weeks, ≥ three times per week). Patients with sleep disturbances (OR: 12.1, CI: 6.77 − 21.6, p < 0.001), trouble falling or staying asleep (OR: 14.6, CI: 5.04–42.0, p < 0.001), and multiple reasons for disturbances (pain, overthinking, or a family death) (OR: 3.58, CI: 1.85–6.93, p < 0.001) had higher odds of inappropriate z-hypnotic use compared to those with no or occasional disturbances. Men had lower odds (OR: 0.54, CI: 0.30–0.97, p = 0.039) than women. GP prescribing was not associated with inappropriate use, but men had lower odds (OR: 0.34, CI: 0.14–0.84, p = 0.020) when prescribed by male GPs compared to women prescribed by female GPs. Conclusion A high proportion of patients used z-hypnotics inappropriately. This inappropriate use was associated with experienced sleep disturbances, particularly trouble falling asleep, trouble staying asleep, and multiple reasons for sleep disturbances. The prescribing GP was not significantly associated with inappropriate use.

Older adults are more likely to suffer from the adverse effects of digoxin. Studies have described the inappropriate use of digoxin in various populations. The objective of this study was to determine the correlates of inappropriate digoxin use in older heart failure patients. We studied older hospitalized heart failure patients with documented left ventricular (LV) function evaluation and electrocardiography. Digoxin use was considered inappropriate if patients had preserved LV systolic function (ejection fraction greater > or =40%) or if they had no atrial fibrillation (AF). We compared baseline patient characteristics by indication for digoxin and tested statistical significance using Pearson's chi-square analysis and Student's t tests. Using logistic regression, we determined the correlates of inappropriate use and initiation of digoxin. Subjects (N = 603) had a mean age of 79 (+/-7) years; 59% were women, and 18% were African American. A total of 376 patients (62%) were discharged on digoxin, and 223 (37%) had no indication for its use. Half of the patients without an indication for digoxin received the drug. Of 132 patients without an indication and not already on digoxin, 38 (29%) were initiated on it. After adjustment for various patient and care characteristics, prior digoxin use (adjusted odds ratio [OR] 11.47, 95% confidence interval [CI] 5.72-23.02) and pulse > or =100/min (adjusted OR 2.33, 95% CI 1.10-4.94) were associated with inappropriate digoxin use. Pulse > or =100/min was also associated with inappropriate initiation of the drug (adjusted OR 2.95, 95% CI 1.28-6.78). Inappropriate use of digoxin was common and was associated with prior use. Tachycardia was associated with inappropriate use and initiation. Electrocardiography and echocardiography should be performed in all older heart failure patients. Digoxin therapy should not be initiated or continued in patients without any evidence of LV systolic dysfunction or chronic AF.