Self-reported sleep disturbance and inappropriate z-hypnotic use among older adults in general practice

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.

Studies have suggested that elderly patients do not always use medications appropriately. Investigations that have relied on prescription claim databases or clinical records focus on acquisition or prescription, and hypotheses must be made to assess actual consumption. Population survey data constitute an altemative way to study inappropriate use. To estimate the prevalence of potentially inappropriate use of medications in elderly patients in Québec based on self-reported use. Using a cross-sectional, general population, health survey in which self-reported medication use in the 2 days prior to the survey was recorded, we estimated the prevalence of inappropriate medication use in elderly patients (> or =65 y old) who responded. Two sets of published criteria were used to define inappropriate use: one to assess use of inappropriate drugs, and another to assess concomitant duplications and potential interactions. Of the 3400 patients surveyed, 6.5% had used > or =1 inappropriate drugs, 2.5% had > or =1 occurrences of potentially inappropriate duplication of medications, and 2.7% had > or =1 potential medication interactions. Concomitant use of at least 2 benzodiazepines was reported by 8.5% of respondents using these drugs. Use of > or =1 long-acting benzodiazepines was reported by 4.2% of the sample. Population health surveys are a useful tool for detecting potentially inappropriate medication use in the elderly. In particular, the high prevalence of inappropriate use of benzodiazepines signals a need for improved detection and intervention in this group.

Inappropriate benzodiazepine use continues to cause substantial morbidity and mortality globally. We aimed to characterise the initiation of new benzodiazepine treatment episodes in Australia and identify correlates of potentially inappropriate benzodiazepine use. We conducted a population-based cohort study using dispensing claims from a 10% sample of Pharmaceutical Benefit Scheme eligible Australians (2014-2017). Our cohort comprised adults initiating a new benzodiazepine treatment; we defined potentially inappropriate use as ≥3 benzodiazepine dispensing over any continuous 90-day period in the year following initiation. We examined characteristics associated with potentially inappropriate benzodiazepine use using multivariable logistic regression. People initiating a new benzodiazepine treatment episode (n = 276 765) were more frequently female (59.1%) and <65 years of age (73.6%). In the 90 days prior to initiating benzodiazepine, people were commonly dispensed antidepressants (26.5%), opioid analgesics (17.6%) and antipsychotics (4.7%). In the first year after initiation, 20 938 (9.5%) people experienced 'potentially inappropriate use'. Having a greater initial quantity of benzodiazepine dispensed [odds ratio (OR), 1.10; 95% confidence interval (CI) 1.08-1.12 per 10 defined daily doses increase], dispensing of antipsychotics (OR 3.00, 95% CI 2.86-3.15) and >5 unique medicines (OR 2.54, 95% CI 2.44-2.64; vs. ≤5 unique medicines) in the 90 days prior to initiation were associated with potentially inappropriate benzodiazepine use. Approximately, 1 in 10 people who initiated benzodiazepines were using it beyond the guideline recommended period. We identified factors at the time of initiation associated with potentially inappropriate use; clinicians should consider these before prescribing benzodiazepines and initiate conversations about alternative therapy when necessary.

Antiplatelet and anticoagulant (collectively called antithrombotics) use remains ubiquitous in older adults due to well-established benefits in treating atherosclerotic and thromboembolic disease. It is unclear whether these benefits outweigh the risk of traumatic hemorrhage in older adults with elevated fall risk. Emergency department (ED) providers are well-positioned to identify opportunities to deprescribe likely inappropriate antithrombotics following an emergency visit for a fall. The objective was to determine the prevalence of likely inappropriate antithrombotic use among older adults on antithrombotics presenting to an ED with a fall. This was a secondary analysis of a prospective cohort study of older adults presenting to an ED with a fall enrolled from 2020 to 2021 in a pharmacist-led medication reconciliation program at a southeastern academic ED. We utilized the Medication Appropriateness Index (MAI) to assess antithrombotic appropriateness, categorized: appropriate (MAI = 0), potentially inappropriate (MAI = 1-2), and likely inappropriate (MAI ≥ 3). 171 out of 514 enrolled patients who presented with a fall to the ED were on an antithrombotic. Their mean age was 81.2 years (std dev 9.2) and 66.1% were female (113/171; 95% CI: 58.6%-72.8%). The median MAI score was 2 (IQR: 2-4). Potentially inappropriate or likely inappropriate use was observed in 82.5% (141/171; 95% CI: 76.0%-87.5%) of participants. Aspirin had the highest prevalence of likely inappropriate use at 60% (59/98; 95% CI: 50%-69%), while P2Y12 inhibitors, warfarin, and direct oral anticoagulants had prevalence of likely inappropriate use at 53% (8/15; 95% CI: 27%-78%), 30% (3/10; 95% CI: 8%-67%), and 29% (21/72; 95% CI: 20%-41%), respectively. There was a high prevalence of likely inappropriate antithrombotic use among older adults presenting to the ED with a fall. While aspirin had the highest rate of likely inappropriate use, all antithrombotics had 30% or greater rates of likely inappropriate use. An ED encounter presents a critical opportunity to evaluate the appropriateness of antithrombotic use in patients who have fallen.

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.

ABSTRACTAlthough the Gerontological Personality Disorders Scale (GPS) can aid in detecting personality disorders (PDs) in older adults in general practice, its availability does not guarantee its use. This study therefore aimed to examine the feasibility and acceptability of the GPS from an older adult, informant, and professional perspective. A convergent parallel mixed methods study was conducted. Qualitative data were collected through semistructured interviews with four general practitioners and four nurse practitioners and were analyzed thematically. Quantitative data were collected through a 5-item questionnaire completed by 329 older adults and 329 informants. The thematic analysis revealed five major themes regarding feasibility and acceptability according to the professionals: taboo to ask intimate questions, quite unfamiliar with these disorders, assets, PDs are a topic of interest in general practice, and preconditions. Descriptive statistics showed that most older adults and informants found the GPS items to be clearly phrased, easy to understand, and nonconfrontational or not unpleasant to answer. The GPS is a feasible and acceptable instrument for detecting PDs in older adults in general practice. Educating professionals about PDs in older adults and the GPS is important prior to its use in daily practice and might further increase its acceptability.

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

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.

Passive body heating in controlled settings could shorten sleep onset latency (SOL). The hypothesized mechanism is vasodilation-induced heat loss before bedtime. However, this evidence is based on small sample-sized studies in specific populations. Thus, we analyzed the association of hot-water bathing and its before-bedtime timing with SOL and heat loss in a large study population of older adults. We conducted a longitudinal analysis using repeated measurements of hot-water bathing and sleep among 1,094 older adults (mean age, 72.0 years). SOL was recorded using actigraphy and self-reported sleep estimates and was categorized into conditions (intervals of 1-60, 61-120, 121-180, and > 181 minutes between hot bath and bedtime) and compared with the control condition of no bathing. The heat-loss indicator, distal-proximal skin temperature gradient, was examined in the same categorization. Mixed-effects linear regression models suggested that the bathing conditions of 61-120 minutes and 121-180 minutes showed significantly shorter log-transformed actigraphic SOL by 0.23 log-minutes (95% confidence interval (CI), 0.03-0.42) and 0.32 log-minutes (95% CI, 0.09-0.56), shorter self-reported SOL by 0.16 log-minutes (95% CI, 0.02-0.30) and 0.18 log-minutes (95% CI, 0.01-0.35), and higher distal-proximal skin temperature gradient for 30 minutes before bedtime by 0.49°C (95% CI, 0.22-0.75) and 0.51°C (95% CI, 0.20-0.83), respectively, independent of potential confounders. Hot-water bathing before bedtime is significantly associated with shorter SOL and higher distal-proximal skin temperature gradient among the large-scale older population. This finding could enhance the generalizability of hot-water bathing habits for ameliorating sleep initiation difficulty.

IntroductionPolypharmacy refers to the concurrent use of multiple medications, while inappropriate drug use occurs when patients take more medications than necessary or use drugs without proper indication. The elderly are...

Background Considering the vulnerability of older adults to adverse drug reactions, medications with strong anticholinergic properties are considered potentially inappropriate for this population. This study aims to characterize older adults’ profile of anticholinergics use and to identify the factors associated with their potentially inappropriate use. Research design and methods A retrospective study was conducted on 1200 older adults in primary health care centers of Portugal between April 2021 and August 2022. Potentially inappropriate use was assessed according to the 2023 Beers criteria. Logistic regression analyses were performed to determine associations between independent variables and potentially inappropriate use. Results A 8.9% (95% CI 0.074–0.107) of the older adults were exposed to one or more potentially inappropriate anticholinergics, and amitriptyline was the most used (2.0%). Multivariate analysis revealed that use was associated with a higher mean number of medications (OR 1.173, 95% CI 1.115–1.234), diagnoses of depression (OR 2.889, 95% CI 1.785–4.674) and psychiatric disorders (OR 1.654, 95% CI 1.003–2.729). Conclusions This study underscores the importance of vigilance in prescribing anticholinergic medications to older adults, particularly those with higher medication burdens and mental health diagnoses. By identifying factors associated with potentially inappropriate use, healthcare providers can better tailor medication regimens to mitigate risks and optimize the well-being of older adults.

BackgroundAs a potent opioid analgesic, fentanyl transdermal patches (FTDs) have been widely used in patients with moderate to severe pain. However, increasing concerns about the opioid epidemic have made it important to strengthen the rational use and management of FTDs.ObjectiveOur objective was to investigate the trends in the use of FTD and to evaluate potentially inappropriate FTD use in patients with noncancer pain, based on established evaluation criteria, referring various recommendations and guidelines.MethodsA nationwide cross-sectional study was conducted using a national insurance claims database from 2014 to 2020. The study included patients who were prescribed FTDs at least once a year in an outpatient setting, while excluding cancer or pediatric patients. To identify potentially inappropriate use, we developed evaluation criteria based on the established recommendations for the safe use of prescription opioids in patients with noncancer pain and assessed each patient’s compliance. The working-age and older adult groups were compared to evaluate the differences in FTD use, and modified Lorenz curves and Gini coefficients were used to assess the equality of FTD use.ResultsA total of 5386 patients and their 19,800 reimbursements were included in the study. The number of patients with FTDs decreased from 58.6 to 53.7 per 100,000 registrants between 2014 and 2020. Meanwhile, the number of reimbursements increased by 7.4%, from 203.2 to 218.1 per 100,000 registrants during the same period. The working-age patients had an average of 3.9 reimbursements per year, with an average morphine milligram equivalent per day (MME/day) of 64.4 for each reimbursement. The older adult patients had an average of 3.5 reimbursements per year, and their average MME/day was 47.9. As a result of applying the evaluation criteria, 567 (24.5%) working-age patients and 531 (17.3%) older adult patients were identified as potentially inappropriate FTD users. Among patients with multiple FTD prescriptions, the working-age group with potentially inappropriate FTD use had significantly higher estimated MME/day than the older adult group (P<.001). The modified Lorenz curve showed that more than 70% of the total FTDs used in the working-age group were consumed by those with potentially inappropriate FTD use, while older adult group with potentially inappropriate FTD use accounted for less than 50% of the total older adult patients. The working-age patients also had a higher Gini coefficient than the older adult group, indicating unequal use of FTDs (0.461 vs 0.406).ConclusionsAlthough the number of patients receiving FTD prescriptions has decreased during the study period, the total amount of FTDs consumed increased, suggesting that caution is warranted. This study also highlights the potential for inappropriate FTD use in working-age patients. Further research is needed to quantify and qualify the risk factors in patients with potentially inappropriate use, given the clinical rationale associated with prescribing FTDs.

ObjectivesLittle is known about the inappropriate use of proton pump inhibitors (PPIs) and how mild cognitive impairment (MCI) and high comorbid burden relate to the inappropriate prescribing of PPIs. Therefore, the current study aimed to examine these associations among community-dwelling older adults in Jordan. MethodThis cross-sectional study was conducted on 215 community-dwelling older adults from three local healthcare centers located in Irbid, Jordan. Data about PPI use, including the name of medication, dose, frequency, duration, and indication, were collected retrospectively from a review of the participating older adults’ medication cards for November and December 2019. The collected data were evaluated based on the Food and Drug Administration (FDA) guidelines. MCI was measured using the Arabic version of the Montreal Cognitive Assessment, and comorbid burden was measured using the Cumulative Illness Rating Scale for Geriatrics. ResultsForty-seven percent of the participants were found to have taken a PPI, with 68 % having taken one for a longer period than recommended by the FDA. Older adults with MCI or high comorbid burden were found to be more susceptible than other older adults to the long-term use of PPIs. The logistic regression revealed that MCI is a statistically significant predictor of inappropriate PPI use (p < 0.001). ConclusionInappropriate PPI use is common among community-dwelling older adults in Jordan, with a significantly higher prevalence of inappropriate PPI use in people with MCI than in people with normal cognitive abilities. Future intervention studies are highly recommended to encourage optimal prescribing of PPIs for community-dwelling older adults.

US Physician Adherence to Standards in Asthma Pharmacotherapy Varies by Patient and Physician Characteristics

Reducing the Inappropriate Use of Antipsychotics in Long-Term Care: Strategies for Success