Issues In Older Patients Research Articles

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review

BackgroundMental illness and medication safety are key priorities for healthcare systems around the world. Despite most patients with mental illness being treated exclusively in primary care, our understanding of medication safety challenges in this setting is fragmented.MethodSix electronic databases were searched between January 2000-January 2023. Google Scholar and reference lists of relevant/included studies were also screened for studies. Included studies reported data on epidemiology, aetiology, or interventions related to medication safety for patients with mental illness in primary care. Medication safety challenges were defined using the drug-related problems (DRPs) categorisation.ResultsSeventy-nine studies were included with 77 (97.5%) reporting on epidemiology, 25 (31.6%) on aetiology, and 18 (22.8%) evaluated an intervention. Studies most commonly (33/79, 41.8%) originated from the United States of America (USA) with the most investigated DRP being non-adherence (62/79, 78.5%). General practice was the most common study setting (31/79, 39.2%) and patients with depression were a common focus (48/79, 60.8%). Aetiological data was presented as either causal (15/25, 60.0%) or as risk factors (10/25, 40.0%). Prescriber-related risk factors/causes were reported in 8/25 (32.0%) studies and patient-related risk factors/causes in 23/25 (92.0%) studies. Interventions to improve adherence rates (11/18, 61.1%) were the most evaluated. Specialist pharmacists provided the majority of interventions (10/18, 55.6%) with eight of these studies involving a medication review/monitoring service. All 18 interventions reported positive improvements on some medication safety outcomes but 6/18 reported little difference between groups for certain medication safety measures.ConclusionPatients with mental illness are at risk of a variety of DRPs in primary care. However, to date, available research exploring DRPs has focused attention on non-adherence and potential prescribing safety issues in older patients with dementia. Our findings highlight the need for further research on the causes of preventable medication incidents and targeted interventions to improve medication safety for patients with mental illness in primary care.

Bedside medication review with cognitive and depression screening by a clinical pharmacist as part of a comprehensive geriatric assessment in hospitalized older patients with polypharmacy: A pilot study.

BackgroundPolypharmacy is highly prevalent in older patients with multimorbidity and is associated with increased risk of adverse drug events. This pilot study investigated the added value of a bedside medication review with cognitive and depression screening by a clinical pharmacist to identify potentially inappropriate medications (PIMs) and medication use issues in older patients with polypharmacy.Methods and resultsIn the period from September 2018 to March 2019, a clinical pharmacist took part in the comprehensive geriatric assessment of 37 older patients hospitalized at Antwerp University Hospital and conducted a medication review consisting of a record review, a bedside interview questionnaire covering medication use, evaluation of cognitive function (abbreviated MMSE), depression (GDS-4), and systematic check for possible PIMs (STOPP/START criteria).Patients were 83±4 years old and on a median of 12 home medications (range 5–20). The clinical pharmacist formulated an average of 7.7 recommendations to optimize medication use per patient, of which 89.9% were considered clinically relevant by the geriatrician. Only 2 out of 286 PIMs were discovered during routine electronic validation of medication prescriptions. Supervision of medication intake was absent in 75% of cognitively impaired patients, but advice to do so was implemented in 86.4% of cases. The multidisciplinary geriatric advice was communicated to the treating physician, who fully implemented 33.8% of the recommendations.ConclusionsBedside medication review with cognitive and depression screening by a clinical pharmacist is useful to discover polypharmacy related problems and medication intake issues in a population of geriatric patients. Systematic screening for cognitive impairment and depression are needed to detect patients in need of support for correct medication use and therapy compliance.

Hemophilia in Patients 50 Years or Older: Quality of Life, Health Maintenance, Cancer Screening and COVID19

INTRODUCTION: Major progress has been made in treatment of patients with hemophilia over the last 30 or 40 years. Factor replacement, eliminating HIV and hepatitis C transmission, and more recently, longer-acting coagulation factors and immune treatments play a role in allowing patients with hemophilia to experience a longer and healthier life. Previous studies show that invasive procedures like colonoscopies, bronchoscopies or biopsies can safely be performed in patients with hemophilia if an appropriate factor replacement is given. However, because of their risk of bleeding, patients with hemophilia may be reluctant to undergo such invasive procedures or get recommended health maintenance, and these fears may have been worsened by the outbreak of COVID19. Therefore, we wondered if older patients with hemophilia have been impacted by the COVID19 pandemic and have received the recommended vaccinations and cancer screenings.METHODS: The data for this study originates in the hemophilia clinics of two academic centers in Kentucky (University of Louisville and University of Kentucky). IRB approval was obtained in both institutions. Surveys were mailed or emailed to patients 50 years of age or older in our database. Follow-up phone calls were made to patients who did not respond. The surveys had 17 health related questions focusing on general well-being, pain, smoking, cancer screening, vaccinations and COVID19. The original survey was performed between 11/2020 and 3/2021 and COVID19 vaccination status was updated in 7/2021. Overall, 50 patients in our database met the study criteria (hemophilia and age 50 years or older) and 36 responded (72%). Some patients did not answer all questions.Patient details are given in Table 1. Median age was 61 years, most patients had mild to moderate hemophilia, three patients were positive for HIV (all with a negative viral load), and 12 had been infected with hepatitis C. Questions related to the impact of COVID19 explored anxiety of leaving the house, meeting with other people, availability of medical appointments, and getting necessary medications. Patients were asked if they received an influenza vaccination and, if older than 60 years, if they had received a pneumonia vaccination.RESULTS: Overall, most patients reported a good quality of life (Table 2). Nevertheless, most were often or always in pain. About half of the patients were on opioid pain medication. A minority took only over the counter pain medication or no pain medication. 57% of respondents had received both vaccinations for COVID19, two-thirds of the unvaccinated planned to get it. 55% of respondents had undergone a colonoscopy in the previous 5 years. Only 18% identified themselves as current smokers. Few men had undergone screening for prostate cancer. Finally, 5 of 32 patients reported a previous diagnosis of cancer (3 patients with localized skin cancer, 2 patients with head and neck cancers).CONCLUSIONS: Quality of life in patients with hemophilia is self-reported as good or excellent in most older patients. However, chronic pain problems persist and are not always sufficiently controlled. One reason may be that many of our patients did not have consistent factor replacements early in their life. Only a minority of patients reported a psychological or physical impact of the COVID19 lockdown. Most patients as of June or July 2021 have been vaccinated against COVID19, however this is probably lower than in an age-matched group. Mayo Clinic's vaccine tracker reported a vaccination rate of 92.3% for the 65 and older age group in Kentucky (as of July 31 st of 2021). The rate of influenza vaccination is probably comparable to rates in other rural communities. The same applies to cancer screening by colonoscopy and PSA screening. The rate of smoking of 18% is relatively low but may suffer from under-reporting. Overall, health maintenance in older patients with hemophilia appears acceptable but can certainly be improved. Limitations of our study are small sample size and that most patients have mild to moderate hemophilia. We plan to expand our study to other centers to get more insight into health issues in older patients with hemophilia. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Factors associated with acute myocardial infarction in older patients after hospitalization with community-acquired pneumonia: a cross-sectional study

BackgroundCommunity-acquired pneumonia (CAP) and acute myocardial infarction cardiovascular (AMI) are two important health issues in older patients. Little is known regarding characteristics of AMI in older patients hospitalized for CAP. Therefore, we investigated the prevalence, characteristics compared with younger patients, impact on clinical outcomes and risk factors of AMI during hospitalization for CAP in geriatric patients.MethodsEleven thousand nine adult inpatients consisted of 5111 patients≥65 years and 5898 patients< 65 years in respiratory ward diagnosed with CAP were retrospectively analyzed by electronic medical records.Results159 (3.1%) older patients in respiratory ward experienced AMI during hospitalization for CAP. AMI were more frequently seen in patients≥65 years compared with patients< 65 years (3.1% vs. 1.0%). Patients≥65 years who experienced AMI during hospitalization for CAP had higher percentage of respiratory failure (P = 0.001), hypertension (P = 0.008), dyspnea (P = 0.046), blood urea nitrogen (BUN) ≥7 mmol/L (P < 0.001), serum sodium< 130 mmol/L (P = 0.005) and had higher in-hospital mortality compared to patients< 65 years (10.1% vs. 6.6%). AMI was associated with increased in-hospital mortality (odds ratio, OR, with 95% confidence interval: 1.49 [1.24–1.82]; P < 0.01). Respiratory failure (OR, 1.34 [1.15–1.54]; P < 0.01), preexisting coronary artery disease (OR, 1.31[1.07–1.59]; P = 0.02), diabetes (OR, 1.26 [1.11–1.42]; P = 0.02) and BUN (OR, 1.23 [1.01–1.49]; P = 0.04) were correlated with the occurrence of AMI in the older patients after hospitalization with CAP.ConclusionsThe incidence of AMI during CAP hospitalization in geriatric patients is notable and have an impact on in-hospital mortality. Respiratory failure, preexisting coronary artery disease, diabetes and BUN was associated with the occurrence of AMI in the older patients after hospitalization with CAP. Particular attention should be paid to older patients with risk factors for AMI.

Polypharmacy and potentially inappropriate medication use in older Indian patients with cancer: A prospective observational study

Background: Polypharmacy and the use of potentially inappropriate medications (PIMs) are important issues in older patients with cancer. Objectives: We aimed to study the prevalence of polypharmacy, and the use of PIMs, including the peri-chemotherapy supportive care regimens in older Indian patients with cancer. Materials and Methods: This was an analysis of a prospective observational study of patients aged 60 years and over with a diagnosis of malignancy who were assessed in the geriatric oncology clinic at the Tata Memorial Hospital (Mumbai, India). Patients on five or more medications were considered to have polypharmacy; excessive polypharmacy was defined as ten or more medications and PIMs were defined and categorized according to the Beers criteria. Results: Between June 2018 and October 2020, 285 patients were enrolled in the study. Polypharmacy was noted in 55% of the patients and excessive polypharmacy in 13%. Polypharmacy was noted in 70% of the patients with lung cancer, compared to 45% for other malignancies, P Conclusions: Polypharmacy and PIM use are common problems in older Indian patients with cancer. Recognizing the problem and taking steps to ensure safe medication prescription practices should be a priority.

Urolithiasis increases the risk of subsequent onset of osteoporosis.

Urolithiasis and osteoporosis are two different pathological entities, but are both important public health issues in older patients. Moreover, the two diseases may share some similar pathogenesis pathway. Currently, few studies focus on the relationship between urolithiasis and osteoporosis. Furthermore, whether the common mobilities influence the long-term osteoporosis rate in urolithiasis patients has never been studied. In the present study, we used the Taiwan National Health Insurance Database (LHID 2000) compiled by the NHI from 1996 to 2013 to determine whether urolithiasis influenced long-term osteoporosis; controls were matched for age, sex, and other comorbidities (including hypertension, diabetes mellitus, dyslipidemia, liver disease, and cardiovascular disease). We included a total of 91,254 patients, including 22,575 patients with urolithiasis and 68,679 control patients. There was a significant difference between the incidence of osteoporosis between the urolithiasis and control groups (adjusted hazard ratio 1.34, 95% CI 1.19-1.79, p < 0.001) during the follow up. The incidence rate of osteoporosis during the follow-up period was 8.87 per 1000 person-years in the urolithiasis group and 6.37 per 1000 person-years in the control group. Based on our results, it is evident that urolithiasis significantly increases the subsequent osteoporosis rate. Though the clinical mechanisms are not fully understood, patients who have a history of urolithiasis may need regular follow-up assessment of bone marrow density.

Comprehensive geriatric assessment predicts azacitidine treatment duration and survival in older patients with myelodysplastic syndromes

BackgroundTreatment of older patients with myelodysplastic syndrome (MDS) is based on disease biology and performance status. Performance status, however, does not reflect increasing co-morbidities, functional dependence or psychosocial issues in older patients. Patients and MethodsThis prospective study evaluated the burden of geriatric related health issues, assessed feasibility of “tailored” Comprehensive Geriatric Assessment (CGA), and compared treatment duration and survival in older patients with MDS and oligoblastic acute myeloid leukemia with and without deficits in CGA domains (n = 98). ResultsAlthough only 27 (28%) patients had an Eastern Cooperative Oncology Group score ≥2, 78% (n = 77) patients had deficits in at least one CGA domain. Deficits were spread across all CGA domains, including dependence for instrumental activity of daily living (iADL; n = 33, 34%).Importantly, patients who were dependent for iADL (3.7 ± 2.6 vs 12.1 ± 7.9; p = .009), had cognitive impairment (3.5 ± 2.1 vs. 10.9 ± 7.9; p = .034) or impaired mobility (3.8 ± 2.5 vs. 13.2 ± 7.6; p = .001) completed significantly less azacitidine cycles as compared to those without these deficits.Cox-proportional regression showed that iADL dependency (hazard ratio 3.37; p = .008) and higher comorbidities (hazard ratio 4.7; p < .001) were associated with poor prognosis independent of disease related factors. Poor survival of iADL dependent patients was seen in both azacitidine (6 vs 19 months; p < .001) and supportive care cohorts (26 vs 48 months; p = .01). ConclusionCGA detected geriatric related health issues, predicted poor survival and identified patients less likely to continue and benefit from azacitidine. Hence, CGA should be included in the treatment decision algorithm of older patients with MDS.

Appetite stimulants for older persons

Anorexia is one of the most common issues in older patients. Although there is a tendency for loss of appetite in older persons due to decreased physical activity and reduced resting metabolic rate, this physiological anorexia of aging can easily develop into progressive anorexia and weight loss. This pathologic anorexia and resultant weight loss is associated with increased morbidity and mortality, especially in the frail elderly. To prevent older persons from entering a vicious cycle of frailty, that is, anorexia-malnutrition-sarcopenia-functional impairment, routine screening for anorexia and malnutrition should be implemented in geriatric clinical practice. All anorexic elderly patients should be strongly encouraged to maintain their nutrition, and appetite stimulants can be considered if non-pharmacological interventions are not effective. Although there are no US or Korea Food and Drug Administration approved medications for geriatric-specific anorexia and weight loss, several appetite stimulants can be prescribed and are used widely. Megestrol acetate is the most widely studied and commonly used of these drugs. Cyproheptadine, dronabinol, mirtazapine, corticosteroids, anabolic steroids (e.g., testosterone or oxandrolone), and growth hormone are also effective in increasing appetite or weight. However, the use of these orexigenic agents should occur only after their benefit-to-risk ratio has been carefully considered.

Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention

OBJECTIVE: To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). STUDY DESIGN: Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. SETTING: Transnational registry in Spain. SUBJECTS: We included 928 patients aged ≥80 years with severe symptomatic AS. INTERVENTIONS: Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. MAIN OUTCOME MEASURES: All-cause death. RESULTS: Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2-38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P = 0.002). CONCLUSION: Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.

Human immunodeficiency virus (HIV) in older people

The number of older people living with human immunodeficiency virus (HIV) in the UK is rising. Older people are at risk of acquiring HIV infection for a multitude of reasons. This, combined with effective HIV treatment which has significantly prolonged life expectancy, means that health care professionals working in the UK can expect to see increasing numbers of older people with HIV infection. In this review article, we summarise the epidemiology of HIV amongst older people, including data from our local cohort in the city of Sheffield, UK. We discuss specific and practical issues in older patients including why older people are at risk, how to make a diagnosis and the importance of doing so early, guidelines for HIV testing and an update on anti-retroviral therapy including drug interactions and side effects.

Secondary Stroke Prevention Strategies for the Oldest Patients

Older adults are not only at higher risk of experiencing stroke, but also have multiple co-morbidities that make treatment for secondary stroke prevention challenging. Very few clinical trials specifically related to secondary stroke prevention treatment efficacy have focused on the oldest-old (>or=85 years) and, therefore, evidence-based recommendations for treatment specific to this population are not available. Some of the special considerations for stroke prevention treatments in older patients include careful titration of blood-pressure-lowering drugs to avoid hypotension, the risk of haemorrhagic stroke with HMG-CoA reductase inhibitors (statins) and weighing the risk of recurrent ischaemia versus bleeding in patients taking antiplatelet or anticoagulant therapy. The risk of peri-procedural complications appears to be high with both carotid angioplasty and stenting and carotid endarterectomy in older patients with carotid stenosis. Other common issues in older patients include adverse drug events, recognizing the risk of dementia, depression and osteoporosis and deciding when to discontinue secondary stroke prevention. In this review, we provide the practitioner with the evidence related to specific approaches to secondary stroke prevention in older patients, and identify the knowledge gaps that currently limit our ability to appropriately treat this vulnerable population.

Death Rattle and Oral Secretions—Second Edition #109

Journal of Palliative MedicineVol. 11, No. 7 FAST FACTS AND CONCEPTSDeath Rattle and Oral Secretions—Second Edition #109Kathleen Bickel and Robert M. ArnoldKathleen BickelSearch for more papers by this author and Robert M. ArnoldSearch for more papers by this authorPublished Online:13 Sep 2008https://doi.org/10.1089/jpm.2008.9865AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail "Death Rattle and Oral Secretions—Second Edition #109." , 11(7), pp. 1040–1041FiguresReferencesRelatedDetailsCited byMolecular structure and quantum chemical evaluation of antiviral drug Atropine using vibrational spectroscopy and in-silico studiesMaterials Today: Proceedings, Vol. 68Dyspnea in the Dying Patient23 April 2021Applications of phytochemicals against nerve agents in counterterrorismManagement of Respiratory Symptoms in Those with Serious IllnessMedical Clinics of North America, Vol. 104, No. 3Dyspnea in the Dying Patient14 May 2016Addressing End-of-Life Issues in Older Patients with Lung Disease16 September 2011Gurgling Breath Sounds May Predict Hospital-Acquired PneumoniaChest, Vol. 138, No. 2Improving quality of life for patients with terminal respiratory disease9 January 2014 | Expert Review of Respiratory Medicine, Vol. 3, No. 6The Last Hours of Living: Practical Advice for CliniciansJournal of the Korean Medical Association, Vol. 52, No. 7 Volume 11Issue 7Sep 2008 Information© 2008 Mary Ann Liebert, Inc.To cite this article:Kathleen Bickel and Robert M. Arnold.Death Rattle and Oral Secretions—Second Edition #109.Journal of Palliative Medicine.Sep 2008.1040-1041.http://doi.org/10.1089/jpm.2008.9865Published in Volume: 11 Issue 7: September 13, 2008PDF download

Mechanical bowel preparation in the older surgical patient

A major risk of colon resection is contamination from the bowel. Poor cleansing of the colon has been associated with an increased incidence of wound infections and intra-abdominal abscesses. Despite controversy on the usefulness of colon cleansing methods, mechanical bowel preparation along with oral and intravenous antibiotics have become common preoperative practice. The population is aging, and surgeons and endoscopists are going to be increasingly involved in the care of older patients. This review focuses on various colon cleansing methods and examines specific issues in older patients.

Mechanical bowel preparation in the older surgical patient

A major risk of colon resection is contamination from the bowel. Poor cleansing of the colon has been associated with an increased incidence of wound infections and intra-abdominal abscesses. Despite controversy on the usefulness of colon cleansing methods, mechanical bowel preparation along with oral and intravenous antibiotics have become common preoperative practice. The population is aging, and surgeons and endoscopists are going to be increasingly involved in the care of older patients. This review focuses on various colon cleansing methods and examines specific issues in older patients.

Elder law, medicare, and legal issues in older patients

Elder law is a specialty area of law directed at the specific needs of older clients and clients with disabilities. This review discusses major legal issues faced by older patients, their families, and their health care providers, including the capacity to consent to treatment, advance directives, and surrogate decision-making. In addition, public benefit programs such as Medicare, Social Security Disability Insurance, Medicaid, and Supplemental Security Income are examined. Available options for long-term care, both institutional and community-based are also highlighted. Finally, elder abuse is discussed. All who provide care to an elder must be aware of the potential signs of abuse and the remedies available.

End of life issues in older patients

Elderly patients with cancer at the end of their life have very unique features associated with their care. As the population of the United States ages, these issues will involve more patients, and end-of-life care has the possibility of consuming more health care costs. With regard to unique care issues, the elderly with cancer at the end of their life are more at risk for untreated pain and depression and are more likely to commit suicide than their younger counter parts. Advance directives are important to discuss with patients and their families so that the patient can designate an individual as the health care proxy and so that discussion around end-of-life care can occur before patients clinically decline so that patients wishes are known and futile care can be avoided. Hospice care is a Medicare-sponsored program that elderly and nonelderly patients can enter for the last 6 months of their lives. This article discusses barriers to hospice referral.

Basic Principles of Working with Older Patients

This article presents essential principles of how to work successfully with older patients. The approach is an interdisciplinary one and the principles are relevant to a broad range of health care professionals including gerontologists, geriatricians, family physicians, social workers, nurses, and allied health personnel. The principles include a synthesis of some of the unique aspects influencing the diagnosis, treatment, and long-term management of health care issues in older patients. It is recommended that trainees in geriatrics and gerontology have these principles presented and discussed by knowledgeable faculty members at the outset of their training experience.