Prescribing In Older Adults Research Articles

Quality of opioid prescribing in older adults with or without Alzheimer disease and related dementia

BackgroundPain is common among individuals with Alzheimer’s disease and related dementias (ADRD), and use of opioids has been increasing over the last decade. Yet, it is unclear to what extent opioids are appropriately prescribed for patients with ADRD and whether the appropriateness of opioid prescribing differs by ADRD status. The objective of this study is to compare the quality of opioid prescribing among patients with or without ADRD who have chronic noncancer pain.MethodsA nationally representative cohort study of Medicare beneficiaries aged 50 years or older who had chronic pain but who had no cancer, hospice, or palliative care from 2011 to 2015. Four indicators of potentially inappropriate opioid prescribing were measured in patients residing in communities (75,258 patients with and 435,870 patients without ADRD); five indicators were assessed in patients in nursing homes (NHs) (37,117 patients with and 5128 patients without ADRD). Each indicator was calculated as the proportion of eligible patients with inappropriate opioid prescribing in the year after a chronic pain diagnosis. Differences in proportions between ADRD and non-ADRD groups were estimated using a generalized linear model adjusting for covariates through inverse probability weighting.ResultsPatients with ADRD versus those without had higher concurrent use of opioids and central nervous system–active drugs (community 44.1% vs 33.3%; NH 58.8% vs 54.1%, both P < 0.001) and no opioids or scheduled pain medications for moderate or severe pain (NH 60.1% vs 52.5%, P < 0.001). The ADRD versus non-ADRD group had higher use of long-term opioids for treating neuropathic pain in communities (21.7% vs 19.5%, P = 0.003) but lower use in NHs (26.9% vs 36.0%, P < 0.001). Use of strong or high-dose opioids when naive to opioids (community 1.5% vs 2.8%; NH 2.5% vs 3.5%) and use of contraindicated opioids (community 0.08% vs 0.12%; NH 0.05% vs 0.21%) were rare for either group.ConclusionPotential inappropriate opioid prescribing in 2 areas of pain care was more common among patients with ADRD than among patients without ADRD in community or NH settings. Further studies aimed at understanding the factors and effects associated with opioid prescribing patterns that deviate from guidelines are warranted.

Prescriber perspectives on low-value prescribing: A qualitative study.

Health systems are increasingly implementing interventions to reduce older patients' use of low-value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood. To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians. Qualitative study using semi-structured interviews. Academic and community primary care practices within University of Pittsburgh Medical Center health system. Sixteen primary care physicians. We elicited 16 prescribers' perspectives on definitions and examples of low-value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low-value prescribing. We identified three key themes. First, prescribers viewed low-value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low-value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low-value prescribing a default practice pattern. Third, interventions addressing low-value prescribing must minimize the cognitive load and time pressures that make low-value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable. Our findings demonstrate that low-value prescribing is a well-recognized phenomenon, and that interventions to reduce low-value prescribing must consider physicians' perspectives and address the specific patient, prescriber and health system factors that make low-value prescribing a default practice.

Potentially inappropriate medication prescribing in older adults: American geriatric society updated beers criteria journey

The present manuscript highlights Beers guidelines till date and puts them at a single platform to enable the physicians, academicians, and patients for the safe and timely use of medicines. Potentially inappropriate medications (PIM) are medications in which adverse risks exceed its health benefits. Complex and multiple comorbidities in older adults make them use multiple drugs that further become a reason for exclusion from randomized clinical trials (RCT). Hence, no set guidelines or RCT-based scientific shreds of evidence are available to support prescription decisions. PIM has become an increasingly common problem in older adults; hence the American Geriatric Society updated Beers criteria; the most crucial strategy to check its use/misuse. The Beers criteria have been formulated in 1991 with the help of validated and appropriate screening tools that explain the use/avoidance of various drugs in older adults based on their health status and are being further updated as and when required. This change in Beers criteria is due to some limitations in the study population, emerging adverse drug reactions/new drug molecules, change in pharmacodynamics of medicines with changing physiology of older adults. Beers guidelines are being updated; however, few significant issues that are not being touched by the committee responsible for constituting the criteria.

925. Adverse Events Due to Inappropriate Prescribing in Older Adults Living with HIV

BackgroundPeople living with HIV (PLWH) are aging and experience age-related comorbidities as well as physiological changes leading to a higher risk for polypharmacy, drug-drug interactions, inappropriate prescribing and related adverse events (AE). Prior studies have highlighted a growing concern for inappropriate prescribing in older PLWH. The objective of this study was to examine the prevalence of AEs resulting from inappropriate prescribing in PLWH > 65 years of age.MethodsThis was a retrospective chart review. PLWH followed-up at the outpatient HIV clinic at the University Hospital in New Mexico between 01/01/2015 and 08/21/ 2018 were eligible if they were > 65 years of age and had >1 potentially inappropriate prescriptions (PIP). PIP were identified using the Beers and STOPP/START criteria for inappropriate mediations in elderly, as well as drugs incorrectly dosed, and potentially deleterious drug-drug interactions (DDI). The University of Liverpool’s HIV interaction checker and Lexicomp’s interaction checker were used to screen for DDI between HIV and non-HIV drugs, and between non-HIV drugs. AEs related to PIPs were collected and their severity was classified using the WHO scale for grading of AEs.ResultsA total of 104 PLWH >65 years of age fulfilled the eligibility criteria. Most patients were male (88.5%) with an average age of 69 years. The majority of patients were virologically suppressed (89%), with an average CD4 cell count of 650 cells/µL. Polypharmacy (>5 non-HIV medications) was identified in all 104 patients; average number of non-HIV medications was 9.4 + 4.8. 30 (28.8%) patients experienced >1 AE, with a total of 53 AEs identified. Of those, 20 (67%) presented with a serious AE. 14 patients (47%) had to seek treatment at an emergency department and 2 patients (7%) had to be hospitalized. The most common AEs included falls (27/53 events; 51%), bleeds (7/53 events; 13%), fractures (4/53 events; 8%). Risk for an AE was significantly associated with increasing number of medications (OR 1.16; 95% CI 1.05-1.29).ConclusionPIP and related AEs are common in older PLWH. Interventions to prevent harm including medication reconciliation, medication review, and medication prioritization according to the risks/benefits of individual patients are warranted.DisclosuresKeenan L. Ryan, PharmD, PhC, Theravance (Advisor or Review Panel member)

Nurse Practitioners’ Experiences of Polypharmacy in Community-Dwelling Older Adults

Numerous studies exist that define polypharmacy and its impact on health. Additionally, the literature is rich in studies documenting the benefits of care provided by nurse practitioners. A gap in research exists at the intersection of the value of nurse practitioners in caring for older adults and their management of polypharmacy. Coinciding with a growth of America’s older adult population and the need for adequate care, the purpose of this study was to explore the experiences of nurse practitioners caring for older adults experiencing polypharmacy. A qualitative descriptive study was conducted using a purposive sampling of nurse practitioners who care for older adults. Interviews were conducted and data was analyzed for themes. Four themes emerged: defining polypharmacy, communicating and collaborating, clinical judgement of nurse practitioners in relation to polypharmacy, and medication issues of older adults. Major themes emerged that depict the complexity of medication management in older adults as well as the important role of NPs in providing care to older adults. The significance of the study findings to future practice includes improving communication and collaboration of prescribing health care providers, better identification and management of polypharmacy, and improving the health care delivered to older adults. Safe and effective prescribing for older adults requires NPs consider the unique needs of each older adult while utilizing technology to support collaboration and decision making.

Prevalence of potentially inappropriate prescribing in older adults in Jordan: Application of the STOPP criteria.

To measure the prevalence of cases of potentially inappropriate prescribing (PIP) for older patients and to identify the risk factors for identified cases of PIP. STOPP criteria version 2 were used for identifying cases of PIP for older patients (>65years) who were admitted to a tertiary hospital in Jordan over a period of 18months. Data were collected by prospectively reviewing the clinical and prescription records of included patients. Descriptive analysis, univariate analysis and multiple linear regression were used to analyse the results. Upon admission, during hospitalisation and on discharge, 144, 182 and 156 cases of PIP were identified, respectively. There was a statistically significant association between the number of prescribed medications and cases of PIP during the hospital journey (P<.05). Inappropriate prescribing of medications is highly prevalent among older patients. Application of validated (STOPP) criteria can help to detect and direct development of interventions to prevent PIP occurrence among older patients.

Barriers to effective prescribing in older adults: applying the theoretical domains framework in the ambulatory setting \u2013 a scoping review

BackgroundAs the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting.MethodsA scoping review was performed based on the five-stage methodological framework developed by Arksey and O’Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data.ResultsA total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as “Knowledge”, “Skills”, and “Social/Professional Role and Identity”; issues with “Environmental Context and Resources”; and the impact of “Social Influences” and “Emotion” on prescribing behaviour.ConclusionThe TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.

Reducing Inappropriate Outpatient Medication Prescribing in Older Adults across Electronic Health Record Systems

The American Geriatrics Society recommends against the use of certain potentially inappropriate medications (PIMs) in older adults. Prescribing of these medications correlates with higher rates of hospital readmissions, morbidity, and mortality. Vanderbilt University Medical Center previously deployed clinical decision support (CDS) to decrease PIM prescribing rates, but recently transitioned to a new electronic health record (EHR). The goal of this study was to evaluate PIM prescribing rates for older adults before and after migration to the new EHR system. We reviewed prescribing rates of PIMs in adults 65 years and older, normalized per 100 total prescriptions from the legacy and new EHR systems between July 1, 2014 and December 31, 2019. The PIM prescribing rates before and after EHR migration during November 2017 were compared using a U-chart and Poisson regression model. Secondary analysis descriptively evaluated the frequency of prescriber acceptance rates in the new EHR. Prescribing rates of PIMs decreased 5.2% (13.5 per 100 prescriptions to 12.8 per 100 prescriptions; p < 0.0001) corresponding to the implementation of alternatives CDS in the legacy EHR. After migration of the alternative CDS from the legacy to the new EHR system, PIM prescribing rates dropped an additional 18.8% (10.4 per 100 prescriptions; p < 0.0001). Acceptance rates of the alternative recommendations for PIMs was low overall at 11.1%. The prescribing rate of PIMs in adults aged 65 years and older was successfully decreased with the implementation of prescribing CDS. This decrease was not only maintained but strengthened by the transition to a new EHR system.

Potentially inappropriate prescribing in older adults with advanced chronic kidney disease.

Older adults with chronic kidney disease (CKD) are at heightened risk for polypharmacy. We examined potentially inappropriate prescribing in this population and whether introducing pharmacists into the ambulatory kidney care model was associated with improved prescribing practices. Retrospective cohort study using linked administrative databases. We included patients with an eGFR ≤30 mL/min/1.73 m2 ≥66 years of age followed in multidisciplinary kidney clinics in Ontario, Canada (n = 25,016 from 28 centres). The primary outcome was the absence of a statin prescription or the receipt of a potentially inappropriate prescription defined by the American Geriatric Society Beers Criteria® and a modified Delphi panel that identified key drugs of concern in CKD. We calculated the crude cumulative incidence and incidence rate for the primary outcome and used change-point regression to determine if a change occurred following pharmacist introduction. There were 6,007 (24%) and 16,497 patients (66%) not prescribed a statin and with ≥1 potentially inappropriate prescription, respectively. The rate of potentially inappropriate prescribing was 125.6 per 100 person-years and was higher in more recent years. The change-point regression analysis included 2,275 patients from two centres. No immediate change was detected at pharmacist introduction, but potentially inappropriate prescribing was increasing pre-pharmacist introduction, and this rising trend was reversed post-pharmacist introduction. The incidence of potentially inappropriate prescribing still remained high post-pharmacist introduction. Potentially inappropriate prescribing practices were common. Incorporating pharmacists into the kidney care model may improve prescribing practices. The role of pharmacists in the ambulatory kidney care team warrants further investigation in a randomized controlled trial.

Does Social Support Affect Older Adults’ General Practitioner Attendance Rates? Findings from the North West Coast Household Health Survey

ABSTRACT Objective The aim of this study was to explore whether social support and socio-economic status have an effect on primary care attendance in older adults (aged 65+). Methods This study used data from the longitudinal North West Coast (NWC) Household Health Survey (HHS) from across 20 disadvantaged and 8 less disadvantaged neighborhoods. Data included the EQ-5D, social support, frailty-related measures, healthcare utilization, and the Index of Multiple Deprivation (IMD). Principal component analysis was used to derive a factor for social support. Poisson regression analysis was employed to explore the effects of frailty, social support, General Practitioner (GP) distance, education, IMD, living situation, and depression on the number of GP attendances in the past 12 months. Results 1,685 older adults were included in this analysis. Of those older adults who visited their GP (87.4%), most had visited their GP twice in the past 12 months. Having an educational qualification, higher levels of social support, and being physically fit reduced GP utilization. Being moderately frail, depressed, and living further away from the nearest GP increased attendance. Older adults living in the most disadvantaged neighborhoods were more likely to visit their GP. Conclusions Increasing social support impacts to a small, but important, extent on reducing GP attendance in older adults. Future research needs to explore whether improving social support in old age can reduce GP utilization. Clinical Implications Findings suggest a need for improving social prescribing in older adults to reduce some GP visits which could be avoided and might not be necessary.

Eliminating medication overload

Eliminating medication overload

Turkish inappropriate medication use in the elderly (TIME) criteria to improve prescribing in older adults: TIME-to-STOP/TIME-to-START

Key summary pointsAimTo meet the current need in different European countries for improving prescribing in older adults, we aimed to create an update screening tool getting origin from the two user friendly criterion sets: the STOPP/STARTv2 criteria and CRIME criteria. FindingsBased on thorough literature review, 55 criteria were added, 17 criteria were removed, and 60 criteria were modified. As a result, 153 TIME criteria composed of 112 TIME-to-STOP and 41 TIME-to-START criteria were introduced.MessageTIME criterion set is an update screening tool reported from Eastern Europe that included experts from geriatrics and other specialties frequently giving care to older adults and some additional practical explanations for clinical use.

Assessment of Inappropriate Prescribing to Elderly Patients in an Internal Medicine Ward According to the 2019 Beers Criteria

Drug prescribing in older adults presents a serious challenge in medical clinical practice as this group of patients is particularly susceptible to drug-related side effects. American Geriatrics Society Beers Criteria serve as guidelines for clinicians to prevent potentially inappropriate prescribing in adults aged 65 years and older. Along with other tools and clinical judgment, these criteria can be used as a prescribing quality indicator. The purpose of this study was to determine the prevalence of potentially inappropriate prescription and the most common potentially inappropriate medications prescribed among older patients at admission in an internal medicine ward, as well as its rate of discontinuation by clinicians by the time of discharge. This assessment was made in light of the American Geriatrics Society 2019 Updated AGS Beers Criteria. Data from three internal medicine wards of the University of Coimbra Hospital Center were analyzed during July 2019, resulting in a total of 153 selected patients. The mean age was 85 (SD 7.32) years and most of the patients were female (58%). On admission, 75% of patients had at least one potentially inappropriate drug prescribed. At discharge, the drug was discontinued in 21% of these patients. One potentially inappropriate drug was introduced in 16% of patients. More than ever, we must acknowledge deprescribing as an important component of a good prescribing continuum. Our results highlight clinicians’ poor recognition of potentially harmful drugs in the elderly and the urge to define a strategy that allows appropriate therapeutic adjustments in this age group.

Medication Use Quality and Safety in Older Adults: 2018 Update.

Improving the quality of medication use and medication safety is an important priority for prescribers who care for older adults. The objective of this article was to identify key articles from 2018 that address these issues. In addition, we selected four of these articles to annotate, critique, and discuss their broader implications for clinical practice. The first study highlights a cluster-randomized trial that utilized a pharmacist-led education-based intervention delivered to both patients and physicians to deprescribe four types of inappropriate medications (sedative-hypnotics, first-generation antihistamines, selective nonsteroidal anti-inflammatory drugs, and glyburide). The second study, a nested case-control study using data from within the UK Clinical Practice Research Datalink, examined the association between anticholinergic exposure, overall and by anticholinergic medication class, and dementia risk in 40 770 older adults. The third study, a longitudinal cohort study of 1028 Swedish older adults, examined the association between antihypertensive medications and incident dementia. The last study was a randomized, double-blind, placebo-controlled trial that investigated the effect of daily low-dose aspirin (100 mg) for primary prevention on cardiovascular events and major hemorrhage in 19 144 community-dwelling older adults. Collectively, this current article provides insight into the pertinent topics of medication use quality and safety in older adults and helps raise awareness about optimal prescribing in older adults. J Am Geriatr Soc 67:2458-2462, 2019.

1105. Statewide, Retrospective, Cohort Study of Medicare Part B Quinolone Prescribing for Cystitis in 2016–2017

BackgroundQuinolones (FQ) are no longer recommended as first-line therapy for cystitis. In 2016, the FDA released a safety communication advising FQ restriction in the treatment of uncomplicated urinary tract infection unless no other options are available. However, little is known about the frequency of FQ (FFQ) prescribing in older adults (OA) receiving antibiotics for cystitis in New York State (NYS). This study compared the FFQ prescribing in OA receiving antibiotics with a diagnosis of cystitis in NYS between 2016 and 2017.MethodsRetrospective, cohort study of (NYS) Part B Medicare fee-for-service beneficiaries in 2016 and 2017 with diagnosis codes for cystitis. All antibiotics prescribed ≤ 3 days after visit were analyzed. FQ were defined as ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin. County-wide data were aggregated into regional data per NYS Department of Health Population Health Improvement Program categories, but New York City counties were not grouped. FFQ was analyzed at the state and regional level and was defined as the total # of FQ prescriptions / total # of antibiotic prescriptions with the diagnostic code for cystitis. χ 2 test and Risk Ratios (RR = 2017 FFQ/2016 FFQ) were used to compare 2016 and 2017 FFQs for the state and for each region using SAS v 9.3 (α = 0.05).Results50,658 antibiotic prescriptions were written for Medicare beneficiaries diagnosed with cystitis in NYS. The statewide FFQ decreased by 14% from 35.9% in 2016 to 31.0% in 2017 (RR: 0.86 [95% CI: 0.84 – 0.88], P < 0.001). FFQ decreased significantly in 11 of 15 regions (P < 0.05, Figures 1 and 2). The median (IQR) FFQ RR for the regions was 0.83 (0.81, 0.87) (Figure 3). The regions (RR [95% CI]) with the largest decrease were Bronx (0.78 [0.67,0.91]), Finger Lakes (0.80 [0.71,0.89]) and Central New York (0.81 [0.72,0.91]). Limited or no changes were observed in Brooklyn (1.01 [0.94, 1.09]), Queens (0.97 [0.88, 1.06]) and Staten Island (0.95 [0.79, 1.13]).ConclusionOn a statewide level, there were significant decreases in FFQ for cystitis in older adults in 2017 compared with 2016. Nevertheless, up to a third of cystitis prescription were for FQ. Future studies should evaluate the appropriateness of FQ for cystitis in OA. Disclosures All authors: No reported disclosures.

Antimicrobial prescribing in older adults.

Infectious diseases pose a significant threat to older adult health and well-being. Determining the appropriate use and selection of antimicrobials in older adults can be challenging. Age-related physiologic changes, multiple comorbidities, and polypharmacy are factors that can make prescribing antimicrobials complicated and the effectiveness of therapy unpredictable.

Antibiotic prescribing for the older adult: beliefs and practices in primary care.

Older adults suffer high morbidity and mortality following serious infections, and hospital admissions with these conditions are increasingly common. Antibiotic prescribing in the older adult population, especially in long-term care facilities, has been argued to be inappropriately high. In order to develop the evidence base and provide support to GPs in achieving antimicrobial stewardship in older adults it is important to understand their attitudes and beliefs toward antibiotic prescribing in this population. To understand the attitudes and beliefs held by GPs regarding antibiotic prescribing in older adults. Semi-structured qualitative interviews were conducted with 28 GPs working in the UK. Data analysis followed a modified framework approach. GPs described antibiotic prescribing in older adults as differing from prescribing in other age groups in a number of ways, including prescribing broad-spectrum, longer and earlier antibiotics in this population. There were also rationales for situations where antibiotics were prescribed despite there being no clear diagnosis of infection. Trials of antibiotics were used both as diagnostic aids and in an attempt to avoid admission. The risks of antibiotics were understood, but in some cases restrictions on antibiotic use were thought to hamper optimal management of infection in this age group. Diagnosing serious infections in older adults is challenging and antibiotic prescribing practices reflect this challenge, but also reflect an absence of clear guidance or evidence. Research that can fill the gaps in the evidence base is required in order to support GPs with their critical antimicrobial stewardship role in this population.

Antidepressant drugs for older patients on polypharmacy: a systematic review reveals best evidence for sertraline

Objectives There is almost no data on antidepressant prescribing in older adults treated with polypharmacy, although this population represents approximately 50% of older patients. These patients are frequently excluded from double-blind randomized controlled trials, meta-analyses and existing treatment guidelines. The main aim of this paper was to identify data on antidepressant prescribing in depressed older adults on polypharmacy using a systematic review. Methods Randomized controlled clinical trials (RCTs) and other clinical trials in Medline/PubMed without language limitation (-2017) were searched to identify those with older depressed patients on polypharmacy. Only elderly patients (>65 years as mean) were included. Only approved antidepressants were included. Results The systematic search identified 26 different clinical trials, although only one clinical open label trial with sertraline met the final inclusion criteria. This sertraline trial indicated the absence of clinically important drug-drug interactions and confirmed the effectiveness and safety of sertraline in routine clinical practice. Heterogeneity in this trial was high in almost all the categories except attrition and reporting bias. Conclusions Sertraline has the highest evidence level in older adults with depression on polypharmacy. According to the results of this review and due to a low number of appropriate trials, a basic understanding of psychopharmacology is the possible approach to avoid serious problematic drug combinations in these patients. Newer RCTs are also urgently needed. This is the first systematic review including patients treated with polypharmacy, and therefore, its results are important in the field of evidence-based medicine.

Antibiotic prophylaxis and clinical outcomes among older adults with recurrent urinary tract infection: cohort study.

clinical guidelines recommend antibiotic prophylaxis for preventing recurrent urinary tract infections (UTIs), but there is little evidence for their effectiveness in older adults. this was a retrospective cohort study of health records from 19,696 adults aged ≥65 with recurrent UTIs. We used prescription records to ascertain ≥3 months' prophylaxis with trimethoprim, cefalexin or nitrofurantoin. We used random effects Cox recurrent event models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for risks of clinical recurrence (primary outcome), acute antibiotic prescribing and hospitalisation. of 4,043 men and 15,653 women aged ≥65 with recurrent UTIs, 508 men (12.6%) and 2,229 women (14.2%) were prescribed antibiotic prophylaxis. In men, prophylaxis was associated with a reduced risk of clinical recurrence (HR, 0.49; 95% CI, 0.45-0.54), acute antibiotic prescribing (HR, 0.54; 95% CI, 0.51-0.57) and UTI-related hospitalisation (HR, 0.78; 95% CI, 0.64-0.94). In women, prophylaxis was also associated with a reduced risk of clinical recurrence (HR, 0.57; 95% CI, 0.55-0.59) and acute antibiotic prescribing (HR, 0.61; 95% CI, 0.59-0.62), but estimates of the risk of UTI-related hospitalisation were inconsistent between our main analysis (HR, 1.16; 95% CI, 1.05-1.28) and sensitivity analysis (HR, 0.82; 95% CI, 0.72-0.94). antibiotic prophylaxis was associated with lower rates of UTI recurrence and acute antibiotic prescribing in older adults. To fully understand the benefits and harms of prophylaxis, further research should determine the frequency of antibiotic-related adverse events and the impact on antimicrobial resistance and quality of life.

Opioid Administration and Prescribing in Older Adults in U.S. Emergency Departments (2005-2015).

IntroductionWe assess trends in opioid administration and prescribing from 2005–2015 in older adults in United States (U.S.) emergency departments (ED).MethodsWe analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) survey from 2005 to 2015. ED visits for painful conditions were selected and stratified by age (18–64, 65–74, 75–84, ≥ 85 years). We analyzed trends in opioid administration in the ED and prescribing at discharge to encounters ≥ 65 and assessed predictors of use using survey-weighted chi-square tests and logistic regression. Trends in the use of five commonly prescribed opioids were also explored.ResultsOpioid administration in the ED and prescribing at discharge for encounters with patients ≥ 65 years fell overall, but not significantly. By contrast, opioid administration in the ED and prescribing at discharge significantly declined for adult encounters 18–64 by 20% and 32%, respectively. A similar proportion of adult encounters ≥ 65 were administered opioids in the ED as 18–64, but adult encounters ≥ 85 had the lowest rates of administration. A smaller proportion of adult encounters ≥ 65 years with painful conditions were prescribed opioids at discharge compared to <65. However, this age-related disparity in prescribing narrowed over the study period. There were shifts in the specific types of opioids administered and prescribed in adult encounters ≥ 65 years over the study period, with the most notable being a 76% increase in hydromorphone administration comparing 2005–06 to 2014–15.ConclusionFrom 2005–15, 1 in 4 to 1 in 10 ED patients with painful conditions were administered or prescribed an opioid in U.S. EDs. Opioids prescribing increased from 2005–11 and then declined from 2012–15, more so among visits in the 18–64 age group compared to ≥ 65 years. Opioid administrating demonstrated a gradual rise and decline in all adult age groups. Age consistently appears to be an important consideration, where opioid prescribing declines with advancing age. Given the nationwide opioid crisis, ED providers should remain vigilant in limiting opioids, particularly in older adults who are at higher risk for adverse effects.