Multiple Prescription Medications Research Articles

Patient Partnership Tools to Support Medication Safety in Community-Dwelling Older Adults: Protocol for a Nonrandomized Stepped Wedge Clinical Trial.

Preventable harms from medications are significant threats to patient safety in community settings, especially among ambulatory older adults on multiple prescription medications. Patients may partner with primary care professionals by taking on active roles in decisions, learning the basics of medication self-management, and working with community resources. This study aims to assess the impact of a set of patient partnership tools that redesign primary care encounters to encourage and empower patients to make more effective use of those encounters to improve medication safety. The study is a nonrandomized, cross-sectional stepped wedge cluster-controlled trial with 1 private family medicine clinic and 2 public safety-net primary care clinics each composing their own cluster. There are 2 intervention sequences with 1 cluster per sequence and 1 control sequence with 1 cluster. Cross-sectional surveys will be taken immediately at the conclusion of visits to the clinics during 6 time periods of 6 weeks each, with a transition period of no data collection during intervention implementation. The number of visits to be surveyed will vary by period and cluster. We plan to recruit patients and professionals for surveys during 405 visits. In the experimental periods, visits will be conducted with two partnership tools and associated clinic process changes: (1) a 1-page visit preparation guide given to relevant patients by clinic staff before seeing the provider, with the intention to improve communication and shared decision-making, and (2) a library of short educational videos that clinic staff encourage patients to watch on medication safety. In the control periods, visits will be conducted with usual care. The primary outcome will be patients' self-efficacy in medication use. The secondary outcomes are medication-related issues such as duplicate therapies identified by primary care providers and assessment of collaborative work during visits. The study was funded in September 2019. Data collection started in April 2023 and ended in December 2023. Data was collected for 405 primary care encounters during that period. As of February 15, 2024, initial descriptive statistics were calculated. Full data analysis is expected to be completed and published in the summer of 2024. This study will assess the impact of patient partnership tools and associated process changes in primary care on medication use self-efficacy and medication-related issues. The study is powered to identify types of patients who may benefit most from patient engagement tools in primary care visits. ClinicalTrials.gov NCT05880368; https://clinicaltrials.gov/study/NCT05880368. DERR1-10.2196/57878.

Use of medication in pregnancy on the rise: Study on 1.4million Danish pregnancies from 1998 to 2018.

Maternal demographics have evolved, and more women than ever enter pregnancy with preexisting comorbidity and with potentially complex medication exposure, including polypharmacy (concomitant intake of multiple medications). This study aims to describe the evolution of medication use in pregnancy in Denmark from 1998 to 2018 with special focus on polypharmacy, patterns of use, and underlying demographics. A Danish nationwide historical registry study based on all clinically recognized pregnancies with a gestation ≥10 weeks between 1998 and 2018. Medication use was estimated by redemption of prescriptions during pregnancy. Among a total of 1 402 327 clinically recognized pregnancies, redemption of at least one prescription medication during pregnancy increased from 56.9% in 1998 to 63.3% in 2018, coinciding with an increased use of polypharmacy (from 24.8% in 1998 to 35.2% in 2018). The prevalence of pregnant women who used medications for chronic conditions increased more than the prevalence of women treated for occasional or short-time conditions. Redemption of one or multiple prescription medications during pregnancy was mostly seen among pregnant women ≥35 years of age. However, pregnant women <25 years old exhibited the largest increase in medication use during the study period. Medication use in general, and polypharmacy in particular, increased from 1998 to 2008, possibly as the result of an increased prevalence of pregnant women with chronic conditions requiring pharmacological treatment. Notably, a marked maternal age-based discrepancy in usage pattern was observed, highlighting the need for further research in this area. The rise in the prevalence of polypharmacy during pregnancy underscores the need for pharmacovigilance to monitor adverse effects. Future studies should investigate the patterns of polypharmacy and the accompanying maternal and fetal risks.

A Systematic Review of Compensation and Technology-Mediated Strategies to Maintain Older Adults’ Medication Adherence

Elderly medication adherence is a challenge in health care. The elderly are often at higher risk for non-adherence, and more likely to be on multiple prescription medications for many comorbidities. This systematic review aimed to explore the current strategies for maintaining older adults' medication adherence with compensation and technology-mediated strategies. We conducted a systematic review to examine related articles published in the PubMed, Web of Science, and Scopus databases, as well as Google Scholar for additional reference sources by cross-reference review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to guide this review. A total of 217 articles were screened, and 27 studies fulfilled the inclusion criteria. Older adults applied a variety of methods to maintain or enhance their medication adherence. Three studies indicated compensation strategies, 19 studies reported technological assistance, two studies used other strategies (community-offered help or caregivers help), and three studies used a combination of compensation with another strategy or technology. Studies identified various compensation- and technology-based strategies carried out by older adults to help remind them to take medication. This review identified potential benefits of technology and compensation strategy implementation in older adults to increase medication adherence. Although we are conscious of the heterogeneity of the included studies, it remains challenging to determine which elements underpin the most effective approaches.

Clinical characteristics, healthcare use, and annual costs among patients with dystrophic epidermolysis bullosa

BackgroundDystrophic epidermolysis bullosa (DEB) is a serious, ultra-rare, genetic blistering disease that requires a multidisciplinary care team and lifelong, proactive disease management. To organize and optimize care, we comprehensively examined diagnoses, healthcare use, and annual costs in patients with DEB across all healthcare settings.MethodsA retrospective study was performed using electronic health record (EHR) data from Optum Clinical Database (January 1, 2016, through June 30, 2020). Patients with an epidermolysis bullosa (EB) diagnosis between July 1, 2016, and December 31, 2019, with ≥ 6 months of baseline and 12 months of follow-up activity were included. Patients were stratified by EB type: recessive DEB (RDEB), dominant DEB (DDEB), DEB (type unknown), and EB unspecified. Demographics, comorbid conditions, and healthcare resource utilization were identified from EHR data. Cost of bandages and total medical costs (US$) were identified from linked claims data.ResultsA total of 412 patients were included, classified as having DDEB (n = 17), RDEB (n = 85), DEB (type unknown; n = 45), and EB unspecified (n = 265). Mean age was 38.4 years, and 41.7% had commercial insurance coverage. The most common comorbidities were mental health disorders, malnutrition, and constipation. Rates of cutaneous squamous cell carcinoma ranged from 0% (DDEB) to 4.4% (RDEB). Prescriptions included antibiotics (56.6%), pain medications (48.3%), and itch medications (50.7%). On average, patients had 19.7 ambulatory visits during the 12-month follow-up, 22.8% had an emergency department visit, and 23.8% had an inpatient stay. Direct medical costs among patients with claims data (n = 92) ranged from $22,179 for EB unspecified to $48,419 for DEB (type unknown).ConclusionsThis study demonstrated the range of comorbidities, multiple healthcare visits and prescription medications, and treatment costs during 1 year of follow-up for patients with DEB. The results underscore that the clinical and economic burden of DEB is substantial and primarily driven by supportive and palliative strategies to manage sequelae of this disease, highlighting the unmet need for treatments that instead directly address the underlying pathology of this disease.

The United States 2020 Census data: implications for precision medicine and theresearch landscape.

The United States 2020 Census data: implications for precision medicine and theresearch landscape.

Outcomes of Direct Oral Anticoagulants Co-Prescribed with Common Interacting Medications

Direct oral anticoagulants (DOACs) can potentially interact with multiple prescription medications. We examined the prevalence of co-prescription of DOACs with interacting medications and its impact on outcomes in patients with atrial fibrillation (AF). Patients with AF treated with a DOAC from 2010 to 2017 at the Mayo Clinic and co-prescribed medications that are inhibitors or inducers of the P-glycoprotein and/or Cytochrome P450 3A4 pathways were identified. The outcomes of stroke, transient ischemic attack, or systemic embolism, major bleeding, and minor bleeds were compared between patients with and without an enzyme inducer. Cox proportional hazards model was used to assess the association between interacting medications and outcomes. Of 8,576 patients with AF (mean age 70 ± 12 years, 35% female) prescribed a DOAC (38.6% apixaban, 35.8% rivaroxaban, 25.6% dabigatran), 2,610 (30.4%) were on at least 1 interacting agent: the majority were on an enzyme inhibitor (n=2,592). Prescribed medications included non-dihydropyridine calcium channel blocker (n=1,412; 16.5%), antiarrhythmic medication (n=790; 9.2%), antidepressant (n=659; 7.7%), antibiotic/antifungal (n=77; 0.90%), antiepileptics (n=17; 0.2%) and immunosuppressant medications (n=19; 0.2%). Patients on an interacting medication were more likely to receive a lower dose of DOAC than indicated by the manufacturer's labeling (15.0% vs 11.4%, p <0.0001). In multivariable analysis, co-prescription of an enzyme inhibitor was not associated with risk of any bleeding (hazard ratio 0.87 [0.71 to 1.05], p=0.15) or stroke, transient ischemic attack, or systemic embolism (hazard ratio 0.82 [0.51 to 1.31], p=0.39). In conclusion, DOACs are co-prescribed with medications with potential interactions in 30.4% of patients with AF. Co-prescription of DOACs and these drugs are not associated with increased risk of adverse embolic or bleeding outcomes in our cohort.

Polypharmacy Exposure, Aging Populations, and COVID-19: Considerations for Healthcare Providers and Public Health Practitioners in Africa.

Given the continent’s growing aging population and expanding prevalence of multimorbidity, polypharmacy is an increasingly dire threat to the health of persons living in Africa. The COVID-19 pandemic has only exacerbated these issues. Widespread misinformation, lack of vaccine access, and attempts to avoid being infected have resulted in increases in Africans’ willingness to take multiple prescription and nonprescription medications and supplements. Issues with counterfeit pharmaceuticals and the relatively new recognition of emergency medicine as a specialty across the continent also create unique challenges for addressing this urgent public health need. Experts have called for more robust pharmaceutical regulation and healthcare/public health infrastructure investments across the continent. However, these changes take time, and more near-term strategies are needed to mitigate current health needs. In this commentary, we present a nonexhaustive set of immediately implementable recommendations that can serve as local strategies to address current polypharmacy-related health needs of Africans. Importantly, our recommendations take into consideration that not all healthcare providers are emergency medicine trained and that local trends related to polypharmacy will change over time and require ever-evolving public health initiatives. Still, by bolstering training to safeguard against provider availability biases, practicing evidence-based prescribing and shared decision making, and tracking and sharing local trends related to polypharmacy, African healthcare providers and public health practitioners can better position themselves to meet population needs. Furthermore, although these recommendations are tailored to Africans, they may also prove useful to providers and practitioners in other regions facing similar challenges.

Extracting Interesting Sequence Association Rules from a High-Dimensional Healthcare Dataset using Multiobjective Metaheuristics

This project is part of a larger research program looking to define, detect and predict dangerous polypharmacy cases, or situations where the prescription of multiple medications has unexpected negative consequences. The main objective of this project is to find interesting association rules between combinations of drugs and health outcomes.

MO492SELF-REPORTED MEDICATION USE AND URINARY DRUG METABOLITES IN THE GERMAN CHRONIC KIDNEY DISEASE (GCKD) STUDY: A PHARMACOMETABOLOMIC APPROACH

Abstract Background and Aims Chronic kidney disease (CKD) patients are prone to prescription of multiple medications. Medication adherence is a well-recognized problem in the management of patients with chronic diseases requiring polypharmacy. This study aimed to evaluate the connection between self-reported medication use and urine drug metabolite levels in a large cohort of CKD patients, the GCKD study, as a basis for future pharmacometabolomics studies. Method Self-reported medication use of 160 substances and 41 medication groups was ascertained at study baseline and coded according to the Anatomical Therapeutic Chemical classification system. A non-targeted mass spectrometry-based approach (Metabolon HD4™) was used for concomitant metabolite quantification in urine. Specificity, sensitivity and accuracy of medication use and the corresponding urine metabolite measurements were calculated. Multivariable regression models (adjusted to age, sex, eGFR, log(UACR), systolic blood pressure, LDL, log(triglycerides), log(HBA1c) were used to establish associations in prescription patterns. Results Among 4,885 participants, 78 drug metabolites were detected in urine (frequency range: 0.4-58%) and assigned into 110 medication – drug metabolite pairs (MMPs) based on reported individual substances and medication groups. For all 68 MMPs of individual substances, accuracy of medication use and the corresponding drug metabolite measurement was excellent (median 97.0%, range 43%-100%), as was measurement-based specificity (median 99.3%, range 73.3%-100%; Fig. 1). Median measurement-based sensitivity was 72.1% (range 1.1%-100%, Fig. 1). Sensitivity and specificity were especially high for angiotensin-II receptor blockers (92%-96%; 99-100%), calcium channel blockers (85-100%; 91-100%), and metoprolol (90%; 98% respectively) commonly prescribed and important medications for blood pressure control and cardiovascular risk reduction in CKD patients. MMPs showing sensitivity &amp;lt;80% included several substances found in over-the-counter (OTC) analgesic medications, suggesting that their use is not always reported. While self-reported use of the OTC analgesics acetaminophen and ibuprofen was &amp;lt;3% each, their corresponding drug metabolites indicated higher usage (acetaminophen: 10-26%; ibuprofen: 10-18%, depending on the number of evaluated drug metabolites). Typical examples of medication co-prescriptions (e.g., trimethoprim and sulfamethoxazole) were detected as the combined presence of their drug metabolites in urine. This result validates the abstraction of single substances from combination medications and this urine-based metabolomic approach. Conclusion This study provides a comprehensive screen of the associations between urine drug metabolite levels and self-reported medication use. It supports the usefulness of pharmacometabolomics to assess medication use, frequency of OTC analgesics use, and prescription patterns in persons with CKD.

Post-Visit Patient Understanding About Newly Prescribed Medications

BackgroundGood patient understanding of basic medication-related information such as directions for use and side effects promotes medication adherence, but information is lacking about how well patients understand basic medication-related information after their office visits.ObjectiveThe purpose of this study is to investigate post-visit patient understanding about newly prescribed medications.DesignSecondary mixed methods analysis comparing patient survey responses about newly prescribed medications to information conveyed by physicians during office visits (from audio recordings of office visits).ParticipantsEighty-one patients aged 50 and older who discussed newly prescribed medications during an outpatient office visit.Main MeasuresAccurate patient identification of medication dose, number of pills, frequency of use, duration of use, and potential side effects.Key ResultsThe 81 patients in this study received 111 newly prescribed medications. For over 70% of all newly prescribed medications, patients correctly identified the number of pills, frequency of use, duration of use, and dose, regardless of whether the physician mentioned the information during the office visit. However, for 34 of 62 medications (55%) for which side effects were not conveyed and 11 of 49 medications (22%) for which physicians discussed side effects, patients reported that the medication lacked side effects. Analysis of transcribed office visits showed that potential reasons for this finding included failure of physicians to mention or to use the term “side effects” during visits, the prescription of multiple medications during the visit, and lack of patient engagement in the conversation.ConclusionsMany patients correctly identified information related to directions for taking a newly prescribed medication, even without physician counseling, but when physicians failed to convey potential medication side effects, many assumed that a medication had no side effects. It may be sufficient for physicians to provide written information about medication directions and dosing, and tailor their limited time to discussing medication side effects.

Multimodal Treatment Patterns for Osteoarthritis and Their Relationship to Patient-Reported Pain Severity: A Cross-Sectional Survey in the United States

PurposeThe purpose of this study was to assess how patient-reported pain is related to osteoarthritis (OA) treatment patterns in routine clinical practice.Patients and MethodsData were collected between February and May 2017 from 153 United States (US) primary care physicians, rheumatologists, and orthopedic surgeons. Each invited up to nine consecutive patients to rate their OA pain in the last week. Physicians provided demographic, clinical, and treatment information for patients, including nonpharmacologic therapies ever recommended, currently recommended over-the-counter (OTC) medications, and currently and ever prescribed medications for the management of OA. Findings for patients with mild (0─3), moderate (4─6), and severe current pain (7─10) were compared using appropriate statistics.ResultsAmong the 841 patients (61% female; mean 65 years; 57% knee OA), 45% reported mild, 36% moderate, and 19% severe current OA pain. Current treatment modalities differed by pain severity (P<0.05). Most patients (70%) had been recommended nonpharmacologic therapy and 40% were currently recommended OTC medications. More patients with moderate (81%) or severe pain (78%) currently received prescription medications, with or without nonpharmacologic therapy, versus those with mild pain (67%). Overall, 47% of patients currently received just one prescription drug, while 49% had received one prescription drug ever. Nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common current (58%) and ever received (88%) prescriptions. Current NSAID prescriptions were not associated with pain severity. Acetaminophen recommendations, opioid prescriptions (current and ever), and multiple prescription medications tried were numerically highest in the severe pain group (all P<0.05 by pain severity). In all groups, >80% of treatment switches were due to lack of efficacy.ConclusionReal-life treatment patterns for OA in the US are significantly associated with current patient-reported pain. Combining nonpharmacologic and pharmacologic treatments is common but higher pain ratings are associated with multiple failed prescription treatments. Current use of acetaminophen and opioids, but not NSAIDs, increases alongside pain severity.

Prescription medications and co‐morbidities in late middle‐age are associated with lower executive function: Results from WRAP

AbstractBackgroundAging is often accompanied by the accumulation of chronic illnesses such as diabetes, cardiovascular disease or hypertension and a corresponding increase in use of medications to manage these conditions. Polypharmacy (use of multiple prescription medications) is a growing health concern and has been associated with poorer clinical outcomes in older adults. This study investigates associations between comorbidities, polypharmacy and longitudinal cognitive performance in an Alzheimer’s disease (AD) risk‐enriched cohort, the Wisconsin Registry for Alzheimer’s Prevention (WRAP).MethodEligible WRAP participants included 1039 (free of dementia or clinical impairment not due to mild cognitive impairment (MCI) and with &gt;=2 visits with cognitive composites, self‐reported health history, and concurrent medication records. Sums of prescribed medications and self‐reported co‐morbidities (include self‐ report over the lifetime) (Table 1) were calculated for each visit and converted to z‐scores for use in mixed effects models of cognition (covariates: age, gender, education, WRAT III reading recognition, practice and study site). Linear mixed effects analyses first examined whether associations between medications, comorbidities and cognitive z‐scores varied across cognitive domains of working memory, immediate recall, delayed recall, executive function, and a preclinical Alzheimer’s cognitive composite (PACC3) before examining associations with each cognitive composite. In secondary analyses, we examined whether number of medications and comorbidities interacted with each other or modified age trajectories.ResultSample characteristics are shown in Table 2 overall and by gender (mean(sd) baseline age=58.99(6.60)). More comorbidities were associated with more prescription medications (Figure 1). More comorbidities and medications were associated with lower executive function (β = ‐0.11, p=.002; β = ‐0.07, p = 0.047; Table 3); using z‐scores of 10th and 90th centile with model parameters, those with low co‐morbidities and medications performed an average of 0.39 SD higher than those elevated on both (Figure 2).ConclusionAssociations between medications, comorbidities, and executive function suggest that persons with more comorbidities and medications may be either at increased risk of reaching clinical levels of impairment earlier than healthier, less medicated peers, or may have potentially reversible clinical impairment. Researchers should be aware of the possibility that medication use and comorbidity may impact cognitive performance (and by extension, adjudicated cognitive status).

An exploration of attitudes and preferences towards medications among healthcare providers and persons with spinal cord injury/dysfunction: a qualitative comparison

Purpose To compare the attitudes and preferences of persons with spinal cord injury/dysfunction (SCI/D) and healthcare providers regarding prescription medications, over-the-counter medications, and natural health products (NHPs). Materials and methods A qualitative study involving semi-structured interviews with healthcare providers (n = 32) and persons with SCI/D (n = 19) in Canada. Inductive descriptive and interpretive analyses were conducted using data display matrices and a constant comparative approach. Results Participants described differing perceptions of therapeutic benefits based on medication type, with shared attitudes about the therapeutic benefits of prescription medications and differing views about the effectiveness of NHPs. Despite the perceived effectiveness of prescription medications, persons with SCI/D preferred to avoid them due to concerns about side effects, safety, and stigma. Persons with SCI/D were often concerned about the long-term safety of prescription medications, whereas providers focused more on medication-related addictions. Participants discussed stigma relating to prescription medications, NHPs, and medicinal marijuana. Conclusion Healthcare providers and persons with SCI/D described different attitudes about and preferences for pharmacotherapeutic products, contributing to challenges in optimizing medication management. Strategies to improve medication management include shared decision-making to incorporate patient preferences into care plans and explicit discussions about long-term medication safety. Further, steps are needed to combat the stigma associated with medication use. Implications for rehabilitation Following a person-centered approach to shared decision-making, prescribers should initiate explicit conversations about patient medication preferences, short and long-term prescription medication side effects, and alternative treatment options. Regarding prescription medication safety, persons with spinal cord injury/dysfunction focused on the long term impact of medications, while providers focused on medication-related addictions, highlighting a disconnect that should be discussed during initiation, continuation, or discontinuation of a medication. Providers should be mindful of the stigma associated with taking multiple prescription medications, including medicinal marijuana, as well as the stigma associated with over-the-counter medications and natural health products. Providers could benefit from education about spinal cord injury/dysfunction-specific prescription medications and could benefit from increased education about natural health products.

The Emerging Risk of Interaction Between Complementary Alternative Medicines and Cardiovascular Medicines

Herbal medicinal use has increased dramatically in recent years. Use of herbal products forms the bulk of treatments, particularly by elderly people who also consume multiple prescription medications for comorbid conditions, which increases the risk of adverse herb-drug-disease interactions. Despite the paucity of scientific evidence supporting the safety or efficacy of herbal products, their widespread promotion in the popular media and the unsubstantiated health care claims about their efficacy drive consumer demand. In this review, we highlight commonly used herbs and their interactions with cardiovascular drugs

Acne related to dietary supplements

Multiple prescription medications may cause or aggravate acne. A number of dietary supplements have also been linked to acne, including those containing vitamins B6/B12, iodine, and whey, as well as "muscle building supplements" that may be contaminated with anabolic-androgenic steroids (AAS). Acne linked to dietary supplements generally resolves following supplement discontinuation. Lesions associated with high-dose vitamin B6 and B12 supplements have been described as monomorphic and although pathogenesis is unknown, a number of hypotheses have been proposed. Iodine-related acne may be related to the use of kelp supplements and has been reported as monomorphic, inflammatory pustules on the face and upper trunk. Whey protein supplements, derived from milk and used for bodybuilding, are associated with papulonodular acne involving the trunk and sometimes the face. Finally, AAS-induced acne has been described as acne fulminans, acne conglobata, and acne papulopustulosa. With studies indicating that about half of US adults report using dietary supplements, it is important that dermatologists directly ask acne patients about their supplement use and educate them on the potential risks of even seemingly innocuous dietary supplements.

Poor Health Literacy and Medication Burden Are Significant Predictors for Inadequate Bowel Preparation in an Urban Tertiary Care Setting.

The goal of this study was to identify factors impacting the quality of bowel preparation in an urban tertiary care setting. Inadequate bowel preparation is encountered in 17% to 32% of colonoscopies performed in the United States. Suboptimal colonic visualization reduces the yield of screening colonoscopies and increases healthcare costs because of longer procedure times and aborted procedures. We performed a cross-sectional survey in patients undergoing outpatient colonoscopy within the Johns Hopkins Health System. A Boston Bowel Preparation Score (BBPS) score of <5 was considered inadequate. Fisher's exact, χ tests and univariate and multivariate binary logistic regression were performed to assess the strength of the association for selected factors with a BBPS<5. In total, 467 patients (76.3% response rate) completed the survey between August 2017 and October 2017. The median BBPS score was 7, and 81.4% of patients had an adequate bowel preparation (BBPS≥5). There was significant association between bowel preparation adequacy and level of education, health literacy, functional status, income, and medication burden. When adjusted for other factors, poor confidence in filling forms (OR, 24.1; P<0.001), multiple daily prescription medications (OR, 12.49; P=0.02) and poor functional status (OR, 2.82; P=0.03) had the highest odds of predicting inadequate bowel preparation. Inadequate bowel preparation is a significant problem accounting for reduced yield of screening and increased health care costs. Poor health literacy, functional status, and number of daily medications are significant factors predicting inadequate bowel preparation in the tertiary care setting.

PMU22 - ANTICHOLINERGIC BURDEN IN OLDER PATIENTS: PHARMACIST INTERVENTION

To analyse the anticholinergic risk (AR) in elderly nursing home patients. Anticholinergic drugs in elderly people have been associated with some serious side-effects, ranging from dry mouth, constipation, and visual impairments to confusion, delirium, and severe cognitive decline. The toxicity is often the result of the cumulative anticholinergic burden of multiple prescription medications and metabolites rather than of a single compound. A cross-sectional study including all elderly patients residing in a nursing home in May 2018. Age, sex and pharmacotherapy were collected for each patient. AR was calculated using an Anticholinergic Burden web tool Calculator which includes 10 different Anticholinergic scales described in a systematic review. The scales offer final AR scores classified in three groups: low, medium and high, according to the risk categorisation made by the authors of each scale. Higher scores are associated with increased AR. We analysed 111 patients; mean age:73.93±8.35 years, 79.28% males. Mean prescribed drugs: 7.39±3.94. There were 16 patients (14.41%) without risk; 35 (31.53%) with medium risk and 35 (31.53%) with high risk. Twenty-five patients (22.52%) did not receive any anticholinergic drug.According to AR score, 70 patients (58.3%) were taking at least one anticholinergic drug, 39 drugs were involved.We identified 39 drugs with anticholinergic potency being the most common: alprazolam (43.6%), mirtazapine (25.6%), lorazepam (23.1%), sertraline (20.5%). Regarding ATC code, drugs from “N05 psycholeptics” group were mainly involved (30.63%); followed by “N06. Psychoanaleptics” (10.81%)and “A10. Drugs used in diabetes”(9.9%). A high proportion of elderly patients are at risk of anticholinergics adverse events because of their prescribed treatment. In consequence, detection of AR can be an important strategy for optimising treatment in these patients, particularly in those suffering from dementia. Pharmaceutical care in elderly nursing home enables the optimisation of pharmacotherapy, improving patient safety. REFERENCES AND/OR ACKNOWLEDGEMENTS All staff of Geriatric-Healthcare Centre.

Improving the Quality of Bowel Preparation for Colonoscopy: Populations to Target in an Urban Tertiary Care Setting

Inadequate bowel preparation is encountered in approximately 17%–27% of outpatient colonoscopies performed in the United States. Poor or incomplete visualization of the colon reduces the yield of screening colonoscopies and increases health care costs due to longer procedure times and aborted procedures. We performed a study to identify factors impacting the quality of bowel preparation, thereby enabling the identification of a population amenable to quality improvement initiatives. We performed a cross-sectional questionnaire survey in patients undergoing outpatient colonoscopy at 2 tertiary care hospitals within the Johns Hopkins Health System. Data on demographic factors, education, health literacy, income, and functional status were recorded. Colonoscopy records were reviewed retrospectively to identify the Boston Bowel Preparation Scale (BBPS) score. A BBPS score of <5 was considered inadequate. Fisher’s exact, χ2 tests, and univariate and multivariate binary logistic regression were performed to assess the strength of the association for selected factors with a BBPS <5. A total of 467 patients completed the survey between August 2017 and October 2017. Most colonoscopies were performed for colorectal cancer (CRC) screening or polyp surveillance (52%). Fifty-eight (12.4%) patients had a family or personal history of CRC. The median BBPS score was 7, and 81.4% of patients had adequate bowel preparation (BBPS ≥5). Using Fisher’s exact or χ2 tests, there was significant association between bowel preparation adequacy and level of education (P = .019), confidence in filling out forms (P = .001), requirement of help with reading hospital materials (P = .011), difficulty learning about medical condition (P = .019), ability to walk 3 city blocks (P = .002), need for help with activities of daily living (P = .001), income (P = .004), and number of daily medications (P = .001). There was no significant association with age, sex, previous successful bowel preparation, bowel preparation agent, patient perception of completion of bowel preparation, and mode of delivery of bowel preparation instructions (letter, phone, or video). When adjusted for functional status, health literacy, education level, income, and number of prescriptions, poor form confidence (odds ratio, 24.1; P < .001) and being on multiple prescription medications (odds ratio, 12.49; P = .02) had the highest odds of predicting inadequate bowel preparation (Table 1). Inadequate bowel preparation is a significant problem, accounting for reduced yield of screening and increased health care costs. Poor health literacy, functional status, and high number of daily medications are significant factors predicting inadequate bowel preparation in the tertiary care setting. Future measures to improve the quality of bowel preparation should target these populations for maximal impact.Table 1Multivariate Logistic Regression for Factors Predicting Inadequate Bowel Preparation (Boston Bowel Preparation Scale Score <5)FactorOR95% CIP valueAOR95% CIP valueForm confidence: How confident are you filling out forms by yourself? Extremely1.00——1.00—— Quite a bit2.170.99–4.78.051.490.53–4.22.45 Somewhat2.370.64–8.80.201.030.11–9.77.98 A little bit6.331.74–23.05.012.200.26–18.82.47 Not at all5.541.56–19.63.0124.142.98–195.70.00Functional status: Because of physical, mental, or emotional problems, do you need the help of any other persons in handling routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes? No1.00——1.00—— Yes3.371.69–6.74.002.821.08–7.33.03Level of education Elementary/middle school3.141.06–9.26.041.130.17–7.39.90 GED2.161.07–4.37.032.260.83–6.20.11 College or higher1.00——1.00——Income <$20,0003.031.28–7.17.010.730.21–2.47.61 $20,000–$30,0002.640.94–7.44.071.330.39–4.51.65 $30,000–$50,0001.080.36–3.29.890.400.10–1.63.20 $50,000–$100,0000.500.16–1.64.250.190.05–0.81.03 ≥$100,0001.00——1.00——No. of daily prescription medications None1.00——1.00—— ≤32.460.53–11.41.252.560.28–23.10.40 4–55.911.30–26.79.0212.491.49–105.09.02 6–88.451.78–40.10.0110.021.10–91.48.04 >87.641.53–38.04.016.170.62–61.15.12AOR, adjusted odds ratio; CI, confidence interval; GED, general educational development; OR, odds ratio. Open table in a new tab

COGNITIVE DYSPHAGIA, POLYPHARMACY AND REPEAT HOSPITALIZATION IN MCI AND DEMENTIA POPULATIONS

Many community-dwelling older adults take multiple prescription medications (e.g. polypharmacy). Polypharmacy (e.g. taking Cevimeline for glaucoma concurrent to taking with Donepezil for Alzheimer's disease and Aclidinium for COPD) has been associated with decrease cognitive and neurological function, which are two key biological systems among the Five Systems of Dysphagia (Winchester & Winchester, 2015). The interaction of polypharmacy, dysphagia (e.g. difficulty swallowing) and repeat hospitalization is clear. Hospital admissions in response to adverse drug reactions have risen in the last 20yrs, particularly for patients that are more than 80yrs old. In frail elderly individuals, adverse drug reactions may present as major geriatric syndromes, such as falls and delirium. Falls and cognitive dysfunction are also associated with complications due to dysphagia. The functional management of the Five Systems of Dysphagia is critical to reducing the likelihood for repeat hospital admissions through the management of aspiration and aspiration pneumonia risk. The consequences of dysphagia can be severe and include dehydration, malnutrition, aspiration, choking, pneumonia and death. Here, we elucidate the relationship among cognitive decline, polypharmacy and the likelihood for going back to the hospital multiple times with increased morbidity and risk for mortality due to aspiration pneumonia. We propose ways to utilize the Interdisciplinary Rehabilitation Team to better serve the aging population suffering from MCI, Alzheimer's disease and/or other forms of cognitive decline.

Economic Burden of Herpes Zoster and Post-Herpetic Neuralgia in Adults 60 Years of Age or Older: Results from a Prospective, Physician Practice-Based Cohort Study in Kushiro, Japan.

Background and ObjectiveHerpes zoster has a high incidence rate among people aged ≥ 60 years and can lead to serious complications such as post-herpetic neuralgia. There are currently no data on the economic burden of herpes zoster and post-herpetic neuralgia in Japan, and the objective of this study was to address this gap.MethodsA total of 412 patients aged ≥ 60 years diagnosed with herpes zoster were recruited. Demographic, clinical, and healthcare resource utilization data on patients with herpes zoster or post-herpetic neuralgia collected via case report forms were used to estimate direct medical cost. Data obtained from a questionnaire survey among patients with herpes zoster/post-herpetic neuralgia were used to estimate transportation cost and productivity loss.ResultsThe mean number of outpatient visits was 5.7. Prescription medications were the main cost driver accounting for 60% of the direct medical cost. The mean direct medical and total herpes zoster-related costs per patient were ¥43,925 and ¥57,112, respectively, and were higher in patients with post-herpetic neuralgia than in those with herpes zoster without complications. Direct medical cost represented 77%, productivity loss 19%, and transportation cost 4% of the total.ConclusionsThis is the first study of the economic burden of herpes zoster and post-herpetic neuralgia in Japan and it demonstrated substantial direct medical cost as a result of the multiple outpatient visits and prescription medications required. These findings provide baseline data for possible future economic evaluations of new herpes zoster/post-herpetic neuralgia interventions.Trial registrationThis cost analysis is part of a prospective, physician practice-based cohort study conducted between June 2013 and February 2015 in Kushiro, Japan (Clinicaltrials.gov identifier NCT01873365, registered on 6 June, 2013).