Prescribing In Elderly Patients Research Articles

Factors associated with potentially inappropriate prescribing in elderly patients with various degrees of chronic kidney disease.

This study aimed to compare the prevalence of potentially inappropriately prescribed drugs in hemodialysis patients and patients with chronic kidney disease who did not require renal replacement therapy, as well as to identify risk factors associated with potentially inappropriate prescribing. The study was designed as a cross-sectional study conducted at the Department of Nephrology, Clinical Center in Nis, Serbia. The patients were divided into two groups: (1) patients on hemodialysis treatment and (2) patients with various degrees of chronic kidney disease without renal replacement therapy. The presence or absence of potentially inappropriate prescribing was determined using the 2015 AGS Beers criteria. The study included a total of 218 patients aged 65 years and over. The number of patients with potentially inappropriate prescribed drugs did not differ significantly (chi-square = 0.000, p = 1.000) between patients on hemodialysis (27 of 83, i.e., 32.5%) and patients with various degrees of chronic kidney disease without renal replacement therapy (44 of 135, i.e., 32.6%). Factors associated with potentially inappropriate prescribing in hemodialysis patients were the number of drugs (hazard ratio [HR] = 1.919, 95% confidence interval [CI]: 1.325-2.780) and number of comorbidities (HR = 1.743, 95% CI: 1.109-2.740). The number of drugs (HR = 1.438, 95% CI: 1.191-1.736) was the only independent factor associated with increased risk of potentially inappropriate prescribing in patients without renal replacement therapy. Our study showed that potentially inappropriate prescribing is a relatively frequent phenomenon present in about a third of patients in both study groups. The number of prescribed drugs was the main factor associated with the increased risk of potentially inappropriate prescribing in both groups.

Prevalence of polypharmacy, drug-drug interactions, and inappropriate prescription in elderly patients with urological cancers.

e23312 Background: Around 50% of new cancer diagnoses occur in patients (pts) > 65 years. Older adults tend to have more comorbidities and therefore prescription of several drugs. Polypharmacy (PP) [defined as prescription of > 5 drugs] has been identified as a prognostic factor and might also lead to relevant drug-drug interactions (DDI) and it is also associated in occasions with inappropriate prescriptions (IP). This study aims to determine prevalence of PP, DDI and potential IP in a uro-oncology clinic. Methods: Pts ≥ 70 years with urological tumors consecutively seen in a medical oncology clinic [May 1st- August31st2023] were offered to complete a questionnaire that included questions about drugs regularly taken, doses, frequency, objective of the treatment along with some key epidemiological data. A descriptive analysis of this information was performed to identify PF along with a search for DDI ( DrugDex ®) and IP (STAR/STOPP criteria). Results: 91 pts agreed to participate and 87 complete the questionnaires. Mean age was 76 years (range 70-91) and 84.5% were men; 64%, 31 and 5% had ECOG 0,1 and 2 respectively. The predominant cancer type was bladder (41%), followed by prostate (40%) and kidney cancer (19%). Polypharmacy was identified in 54 pts (62%), with 12 pts (22%) having ≥ 10 drugs prescribed. Two cases (2%) of duplicity of treatment were found (laxative; hypnotic). Ninety-five major and 37 moderate DDI were detected, of which 8 occurred between anticancer drugs (abiraterone, pazopanib, everolimus and carboplatin) and outpatient treatments. An IP analysis is being currently conducted and data will be presented at the meeting. Conclusions: Our study shows a high prevalence of polypharmacy in older adults with urological tumors and a significant rate of drug-drug interactions including interferences with oncological treatments. These results highlight the need for careful reviewing and monitoring the drugs prescribed to our patients in the clinic and calls for strengthen collaborations with pharmacists and nurses to optimize integral management of GU cancer patients.

Association between frailty and inappropriate prescribing in elderly patients admitted to an Acute Care of the Elderly Unit.

The aim of this study is to analyze the association between the degree of frailty and inappropriate prescribing patterns at admission to an Acute Care of the Elderly Unit (ACE Unit). Prospective observational study conducted in the ACE Unit of an acute hospital in Barcelona city between June and August 2021. Epidemiological and demographic data were collected during hospitalization. Comprehensive geriatric assessment was performed on admitted patients. We recorded frailty (FRAIL scale), extreme polypharmacy (10 or more drugs), central nervous system potentially inappropriate medications-PIMs (STOPP-CNS or group D), cardiovascular potential prescribing omissions-PPOs (START-CV or group A), and anticholinergic burden using the drug burden index (DBI). Ninety-three patients were included, of whom 48 (51.6%) were male, with a mean age of 82.83 (SD 7.53) years. The main diagnosis upon admission was heart failure in 34 patients (36.6%). Frail patients were older, with more dependence of activities of daily living and more comorbidity than non-frail patients. Additionally, frail patients demonstrated more omissions according to the START-A criteria. No statistically significant differences were observed in term of extreme polypharmacy, PIMs, or anticholinergic burden. In the current study we found an association between frailty and inappropriate prescribing, specifically with regard to omissions using the START criteria for the cardiovascular system (group A). Notably, frail patients exhibited more omissions compared to their non-frail counterparts, and this difference was statistically significant.

2048 Antipsychotic medication prescription in elderly patients in Royal Gwent Hospital, Wales

Abstract Introduction he use of anti-psychotics is higher in older people than their younger adult counterparts due to high prevalence of dementia/delirium. Anti-psychotic drugs cause side effects which include cardiovascular, metabolic, extra pyramidal and risk of falls. So, we set out to do a QIP on antipsychotic medication prescription on our Geriatric wards comparing it with NICE guidelines. Method We had 2 approaches to use. Firstly, we prepared a check list for anti-psychotic medication monitoring according to NICE guidelines 2021 and we applied this retrospectively to our patients who had been initiated on anti-psychotics within the last year, the aim being to compare our practice with best practice. Secondly, we prepared a questionnaire for doctors to assess their knowledge about anti-psychotic NICE guidelines and distributed this to our junior doctors in RGH. Results • Main Indication for prescription was Behavioural and psychological symptoms of dementia (BPSD) - 94% of the time • Risperidone was the most commonly prescribed (64%) antipsychotic. • 83% of them had non-pharmacological methods tried before considering antipsychotic medications. • 82% had their baseline ECGs checked and falls risk assessments done • 35% had their lipids checked and 47% had their HbA1c checked • 52% of the doctors were aware about NICE guidelines on prescribing anti-psychotic medications • 70% of the doctors had knowledge about the side effects. Conclusions Our study showed the most commonly used antipsychotic drug was risperidone. We were good at documenting the indication, trying non-pharmacological methods and discussing side effects with patients/family. Hba1c, lipids and prolactin were not often checked, showing room to develop best practice. We are in the process of finalising stickers as a checklist when starting antipsychotics. To improve knowledge, we have presented the findings and aim to put up posters on wards and to do regular teachings.

Potentially inappropriate prescribing in elderly patients with epilepsy at two referral hospitals in Ethiopia.

The prevalence of drug therapy problems in patients with epilepsy has been reported to be as high as 70-90%. Moreover, elderly patients with epilepsy are highly vulnerable to inappropriate therapies. This study aimed to evaluate potentially inappropriate prescriptions (PIP) in elderly patients with epilepsy at the adult neurology clinics of two referral hospitals in Addis Ababa, Ethiopia. A cross-sectional study was conducted on 81 patients with epilepsy and the medication appropriateness index (MAI), the Beers, and Screening Tool of Older Persons' Prescriptions and Screening Tool to Alert to the Right Treatment (STOPP/START) criteria were used to assess PIP. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 25. Of the 81 study participants, 41(50.6%) were male, and the mean age was 67.33 ± 17.43 years. One-fourth of the study participants (25.9%) had polypharmacy and drug-drug interactions (DDIs) were documented in 64 (79%) patients. Based on the MAI, of the 263 medications that were prescribed for elderly epileptic patients, 110 (41.8%) had drug interactions, 44 (16.7%) had inappropriate indications, 31 (11.8%) were ineffective, and 12 (4.6%) were prescribed incorrect doses. Based on the STOPP and START criteria, PIP was reported in 31(38.3%) and 13(16.1%) patients, respectively. Polypharmacy and DDIs are common in elderly epilepsy patients. The MAI, Beer's criteria, and STOPP/START criteria indicate a high prevalence of PIP in elderly patients with epilepsy.

Thiazide-associated hyponatremia increases the risk of major adverse cardiovascular events among elderly Taiwanese patients

BackgroundThiazide-associated hyponatremia (TAH) has been supposed to increase the risk of major adverse cardiovascular events (MACE) in the elderly. Therefore, this study aimed to evaluate the association of TAH with the risk of MACE in elderly Taiwanese patients.MethodsData from the longitudinal generation tracking database (LGTD 2010) of the Health and Welfare Data Science Center (HWDC) were retrospectively assessed. The TAH study group was defined as using > 30 cumulative daily defined doses (CDDDs) thiazide diuretics within one year before diagnosis of hyponatremia. The control group (1:3 propensity score matching) had no diagnosis of hyponatremia but had used > 30 CDDDs thiazide diuretics within one year. Data on MACE were extracted using International Classification of Diseases codes. Outcomes were assessed using a multivariable Cox proportional hazard model and Kaplan-Meier analysis.ResultsA total of 1155 and 3465 individuals were enrolled in the TAH and the control groups, respectively. The rates of MACE (11.1% vs. 7.3%) and death (22.8% vs.12.2%) were significantly higher in the TAH group than the control group. In the TAH group, the adjusted HRs were 1.29 (CI 1.01 ‒ 1.65) for MACE, 1.39 (CI 1.19 ‒ 1.63) for all-cause death, and 1.61 (CI 0.90 ‒ 2.92) for stroke.ConclusionTAH in patients above 65-years-old is associated with a 29% higher risk of MACE, 39% higher risk of all-cause death, and 61% higher risk of stroke. This work suggests that thiazides prescription in elderly patients should be more careful. However, further research is required to confirm our findings.

Is paracetamol prescribed appropriately in elderly patients admitted for a fall? – A Geriatrician’s perspective

Background Paracetamol is a commonly used analgesic among older adults. There have been reports of adverse events with chronic paracetamol use even at therapeutic doses. The objective of this clinical audit is twofold – 1. To evaluate the prevalence of inappropriate paracetamol prescription in the elderly admitted for falls; 2. To introduce strategies to reduce the rate of inappropriate paracetamol prescription in this population. Methods A clinical audit was performed on 100 patients aged 75 years and older who were admitted to the Geriatric Medicine department of a tertiary hospital between July 2019 and October 2019 with a primary diagnosis of a fall. Data collected included demographic data, relevant medical history of cirrhosis, cognitive impairment, alcohol use and weight <50 kg, prescription pattern of paracetamol on day 1 or two of admission and on discharge as well as clinical data on the documented indications for paracetamol use. Results Paracetamol was prescribed in 84 patients. Out of these 84 patients, 56 were prescribed round-the-clock paracetamol with a median duration of 9 (IQR = 10) days. In this group, paracetamol use was inappropriate in 32 (57%) of them and 32 (57%) patients were discharged with round-the-clock paracetamol for a median duration of 17.5 (IQR = 46) days. Conclusion This clinical audit revealed a high prevalence of round-the-clock and inappropriate paracetamol prescription in elderly patients admitted for a fall. Moving forward, we hope that the implementation of a paracetamol prescribing algorithm may reduce the rates of inappropriate paracetamol prescribing in this population.

Multimorbidity, polypharmacy and inappropriate prescribing in elderly patients with atrial fibrillation: A report from the China Atrial Fibrillation Registry Study

BackgroundMultimorbidity, polypharmacy and inappropriate prescribing is common in elderly patients worldwide. We aimed to explore the current status of multimorbidity, polypharmacy and the appropriateness of pharmacological therapy among elderly patients with atrial fibrillation (AF) in China.Materials and methodsWe randomly selected 500 patients aged 65 years or older from the China AF Registry study. Multimorbidity was defined as ≥2 comorbidities and polypharmacy was defined as ≥5 long-term prescribed drugs. Appropriateness of prescribing was evaluated using the Screening Tool of Older People’s Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria version 2. Patients’ attitudes toward polypharmacy were evaluated by the Patients’ Attitudes Towards Deprescribing (PATD) questionnaire.ResultsAmong the 500 patients included (mean age 75.2 ± 6.7 years, 49.0% male), 98.0% had multimorbidity and 49.4% had polypharmacy. The prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) was 43.6% (n = 218) and 71.6% (n = 358), respectively. Traditional Chinese medicine attributed largely to PIMs. Anticoagulants were the most common PPOs. Many clinical factors increased the risk of PIMs and PPOs. However, polypharmacy increased the risk of PIMs (OR 2.70, 95%CI 1.78–4.11; p < 0.0001), but not PPOs. In addition, 73.7% patients with polypharmacy were willing to have one or more of their medications prescribed if advised by their doctor.ConclusionMultimorbidity and polypharmacy were highly prevalent in elderly patients with AF in China. A high prevalence of inappropriate prescribing was also observed. Therefore, much more attention should be paid to the serious health problem in the elderly population.

Polypharmacy and inappropriate prescribing in elderly patients: a retrospective study at Buriadah Central Hospital, Saudi Arabia.

An increase in life expectancy has been attributed to better access to health care and viable treatment options for diseases where there were none before. However, a multiple-drug regimen increases the risk of inappropriate prescription and drug-related problems. This study aimed to investigate polypharmacy and inappropriate prescription among elderly patients in the Qassim region of Saudi Arabia. This was a retrospective study wherein the electronic files of patients aged ≥ 60 years were reviewed and investigated for polypharmacy and inappropriate drug prescription using Beer's criteria 2019. The 1123 patients who met the eligibility criteria were between 60-102 years of age (mean age: 71.9 years). 387 patients (34.46%) used five medications, while the remaining patients used more than five medications. The prevalence of potentially inappropriate medications (PIMs) was 66.25%. The most commonly prescribed PIMs were non-steroidal anti-inflammatory drugs, baclofen, proton pump inhibitors, diuretics, and aspirin (11.3%, 10.6%, 10.1%, 8.46%, and 5.6%, respectively). This study showed a high prevalence of polypharmacy, which consequently led to a high prevalence of PIMs. This is a serious health problem in the elderly population and should be prevented or tackled with caution.

Detection of Potentially Inappropriate Medication in Elderly Outpatient Based on The Beer’s Criteria 2019

Background: Elderly patients generally have more than one disease, so they need several drugs to treat the condition and Potentially Inappropriate Medication (PIM). Objective: This study aimed to examine the inaccuracy of prescription drugs in the elderly using Beer's criteria 2019. Methods: The research method used an observational study with a descriptive cross-sectional design. Beer's Criteria 2019 was compiled by The American Geriatrics Society (AGS) and grouped PIM into five categories. A total of 138 prescriptions met the inclusion criteria at the Internal Medicine Clinic. Results: The results showed that the elderly who received the prescription was in the age range of 60-69 years (73.2%), male gender (54%), and had comorbidity (77.5%). Of the 138 prescriptions for elderly patients, 117 prescriptions for elderly patients experienced PIM incidence (84.78%). The percentage of PIM incidents was based on categories; namely, category 1 was 74.2%, category 2 was 3.5%, 3 was 16.7%, category 4 was 3%, and category 5 was 2.5%. Medicines that include PIM in category 1 are lansoprazole, glimepiride, glibenclamide, alprazolam, diazepam, amitriptyline, diclofenac sodium, ibuprofen, meloxicam. PIM in category 2 are cilostazol, pioglitazone, and diclofenac sodium. Category 3 PIMs include furosemide, spironolactone, and hydrochlorothiazide (HCT), category 4 PIMs include dexamethasone-sodium diclofenac, methylprednisolone-ibuprofen, and alprazolam-codeine, and category 5 PIMs include spironolactone, ciprofloxacin, and ranitidine.. Conclusion: This study concludes that the elderly are at risk for receiving inappropriate drug prescriptions. Patients received more drugs belonging to category 1 PIM than category 2, 3, 4, and 5.

General antidepressants prescribing trends 2009–2018 in Slovenia: a cross-sectional retrospective database study

Background Antidepressants are one of the most frequently prescribed groups of medications. The aim of the study was to evaluate the prevalence and patterns of antidepressants prescribed between 2009 and 2018 in Slovenia in different patient-age groups. Methods This retrospective cross-sectional study performed a nationwide database analysis of all outpatient antidepressant prescriptions based on Slovenian health claims data. Prevalence was defined as number of recipients prescribed at least one antidepressant per 1000 inhabitants. Antidepressant consumption was presented as total dispensed defined daily doses per year. Results In 2018, 147,300 patients were prescribed at least one antidepressant. The prevalence had increased by 16% in ten years and by 7.6% in age standardised data. The largest increase in prevalence was seen in the oldest patients (>80 years, 25% increase); of these, antidepressants are now prescribed to 1 in 4. Use of antidepressants had increased by 38%, suggesting longer treatment duration, increase in dose prescribed or both. SSRIs (selective serotonin reuptake inhibitors) were the most prescribed antidepressants (70% share), with escitalopram and sertraline the most commonly prescribed antidepressants. Conclusion The prevalence of antidepressant prescribing and antidepressant consumption is increasing, mainly due to the population ageing and the increasing prescribing in elderly patients. Key Points The prevalence of antidepressant prescribing as well as antidepressants’ consumption is increasing, reflecting both population ageing and rising prescribing rates. The increase in prevalence and consumption is most dramatic in the oldest patients (over 80 years of age). SSRIs continue to be the most commonly prescribed antidepressants, whilst prescribing of SNRIs is increasing. Future research should focus on evaluating appropriate prescribing of antidepressants (treatment selection, dosage and duration), especially in the elderly.

Potentially Inappropriate Medication Prescribing in Elderly Hypertensive Patients in the Primary Care Unit

Background: Pharmacotherapy is necessary in the treatment of chronic diseases. However, potential inappropriate medication (PIM) prescriptions are associated with adverse events, especially in the elderly. Objective: To quantify the prevalence and classify the type of PIM prescribing in elderly patients with hypertension, in a primary care unit (PCU) of a tertiary hospital, as well as to study factors associated with PIM prescription. Materials and Methods: A retrospective medical record review was conducted in elderly patients followed up for treatment of hypertension at the PCU, between January 1 and December 31, 2018. Beers criteria were used to identify PIM. Factors associated with PIM prescription were analyzed using generalized estimating equation (GEE) modeling analysis. Results: Nine hundred sixty-six subjects were included in the present study with 61.4% female and a median age (Q1, Q3) of 72.5 (68.5, 78.0) years. The prevalence of PIM was 66.9%. Most common PIM were diuretics (28.9%), aspirin (10.2%), and benzodiazepines (9.1%). The associated factors of PIM prescription were being female, visiting the PCU with an acute illness only, and the number of drugs prescribed [adjusted OR (95% CI): 1.60 (1.24 to 2.06), 2.32 (1.45 to 3.70), and 1.73 (1.61 to 1.86), respectively]. Conclusion: The prevalence of PIM prescription among elderly hypertensive patients was high, especially female patients, patients with a high number of medications prescribed, and patients visiting the OPD with acute illnesses. Appropriate medication prescribing can reduce preventable adverse drug events from PIM prescription. Using explicit criteria for prescription is one such useful method. Keywords: Inappropriate medications prescription; Hypertension; Elderly; Primary care unit

Is the oncotype DX test useful in elderly breast cancer patients: a subgroup analysis of real-life Italian PONDx study.

The 21-gene Oncotype DX Breast Recurrence Score® test, (Genomic Health, Redwood City CA) has not been formally evaluated in an older cohort with estrogen receptor (ER)-positive breast cancer (BC) in term of physicians' treatment decisions. We determine the utility of Recurrence Score® (RS) result on adjuvant therapy prescription in elderly patients with resected early BC. PONDx was a multicenter, prospective, observational study, and which investigated the real-life use of the Oncotype DX® test by physicians treating early BC patients in clinical practice. Data from the elderly extracted from 1724 BC patients who underwent Oncotype DX testing were available from 27 reference centers located in 6 regions of Italy (Lombardia, Lazio, Emilia Romagna, Campania, Abruzzo, and Marche). A total of 230 patients (13% of the total population) aged > 70years were analyzed. The study primarily evaluated the impact of the Oncotype DX test on adjuvant treatment decisions. Physicians chosen chemotherapy plus endocrine therapy in 36% of elderly patients and 46% of those 50-70years before the Oncotype DX test. After knowing the RS data, these rates fell to 23 and 33% (38 and 28% relative reduction, respectively). 21-gene test may be helpful even in a relatively low-risk group as elderly patients and may avoid the toxicity of adjuvant chemotherapy in a significant amount. If the Oncotype DX test is currently adopted on a large scale among the elderly and may impact the general prognosis of elderly BC patients, it is challenging and still unproven.

Assessment of Prescriptions in Elderly Patients Hospitalized in Medicine Departments.

Drug-related iatrogenesis is an important issue in the elderly population, and preventing iatrogenic accidents helps to reduce hospitalizations. Our study’s objective was to evaluate prescriptions in the geriatric population of our establishment. The study conducted is a targeted clinical audit. Ten criteria were tested on the hospital prescriptions of people over 75 years old in 11 medical departments, before and after improvement actions. The non-compliance threshold was set at 10% of prescriptions for each criterion. In each phase, 165 patients were included. Four criteria were non-compliant (NC) in the first phase: the presence of Potentially Inappropriate Medications for the Elderly (PIMs) (NC = 57.6%), the adaptation of the medication to renal clearance (NC = 24.9%), the presence of illogical combination (NC = 9.7%), and the total anti-cholinergic score of the prescription (NC = 12.1%). After the implementation of improvement actions, the number of non-compliant criteria decreased between the two phases, from four to two. We obtained a significant improvement for three of the four criteria found to be non-compliant in the first phase. The criterion adaptation to renal function is close to compliance (NC = 10.1%) and the PIMs criterion remained non-compliant after reassessment (NC = 32.1%). Vigilance must be ongoing in order to limit drug iatrogeny, particularly in frail elderly patients.

Antibiotics prescription in the elderly across different clinical areas; A real-life clinical audit

Ageing of the population represents a great challenge to the national health system (NHS) in the UK. Patients in this age group have multiple comorbidities and use polypharmacy. They also have alterations in the absorption, metabolism and excretion of drugs. These factors make them susceptible to developing side effects and drug interactions on using antibiotics.Our team audited the safety of antibiotic prescription in elderly patients (above 85 years of age) in regards to the selection of the appropriate antibiotics, and the documentation of the indication and duration of them. We also compared the prescription process during working hours and out of hours. We recruited 20 patients from each of the three departments involved in their care: The Old people admission unit (OPAU), the geriatric wards and other hospital wards. Our minimum compliance rate was 95% in each of the studied parameters. We spotted a significant compromise in the antibiotic prescription on non-geriatric wards and out of hours. This goes with the concerns raised by other studies. We recommend continuous education and the setting up of campaigns to increase the awareness of the medical staff on this aspect.

Long-term opioid use in seniors following hip and knee arthroplasty in Ontario: a historical cohort study.

Canadian seniors who undergo hip and knee arthroplasty often experience significant postoperative pain, which could result in persistent opioid use. We aimed to document the impact of preoperative opioid use and other characteristics on postoperative opioid prescriptions in elderly patients following hip and knee replacement before widespread dissemination of opioid reduction strategies. We conducted a historical cohort study to evaluate postoperative opioid use in patients over 65 yr undergoing primary total hip and knee replacement over a ten-year period from 1 April 2006 to 31 March 2016, using linked de-identified Ontario administrative data. We determinedthe useof preoperative opioids and the duration of postoperative opioid prescriptions (short-term [1-90 days], prolonged [91-180 days], chronic [181-365 days], or undocumented). The study included 49,638 hip and 85,558 knee replacement patients. Eighteen percent of hip and 21% of knee replacement patients received an opioid prescription within 90 days before surgery. Postoperatively, 51% of patients filled opioid prescriptions for 1-90 days, while 24% of hip and 29% of knee replacement patients filled prescriptions between 6 and 12 months, with no impact of preoperative opioid use. Residence in long-term care was a significant predictor of chronic opioid use (hip: odds ratio [OR], 2.64; 95% confidence interval [CI], 1.93 to 3.59; knee: OR, 2.46; 95% CI, 1.75 to 3.45); other risk factors included female sex and increased comorbidities. Despite a main goal of joint arthroplasty being relief of pain, seniors commonly remained on postoperative opioids, even if not receiving opioids before surgery. Opioid reduction strategies need to be implemented at the surgical, primary physician, long-term care, and patient levels. These findings form a basis for future investigations following implementation of opioid reduction approaches.

528 EVALUATING THE PRESCRIPTION OF OPIATES IN PATIENTS WITH NECK OF FEMUR FRACTURES IN OUT OF HOSPITAL AND EMERGENCY CARE SETTING

Abstract Introduction Opiate based analgesia forms a key component of Hip Fracture management. If prescribed inappropriately, opiate based analgesia can lead to respiratory depression, nephrotoxicity, and delayed recovery. The aim of this project was to evaluate opiate prescription in NOF patients in both out of hospital (OOH) and Emergency Department (ED). Methods 100 consecutive patients were identified from National Hip Fracture Database between January and August 2019. Medical records were reviewed in both care settings, reviewing dose of morphine in comparison to body weight and renal function. Outcomes measured include constipation, acute kidney injury, respiratory compromise, and mortality. Statistical tests (t-test and chi square) were used to discern significance. Following the first cycle of results, results were disseminated to paramedics and at local governance meetings. Teaching was undertaken to increase awareness of harms associated with inappropriate opiate prescribing. A second cycle evaluated 30 consecutive NOFs from July 2020. Results In our study population, 74% were female and the average age was 84. The range of morphine doses given OOH ranged from 2-40 mg, in comparison to 2.5-20 mg in ED. 18% of patient suffered from Respiratory depression with 48 hours of their admission with a further 7% suffering from an acute kidney injury. After intervention, OOH morphine doses ranged between 5-10 mg, a reduction of 75% on maximum dose, with increased use of adjuvants as guided by the WHO pain ladder. No adverse outcomes were noted within 48 hours of admission. Conclusion Patient safety should be high on the agenda whilst caring for frail patients with Hip Fractures and opiate prescription is one of the most critical in the patient’s journey. Reducing harm by prescribing the optimal opiates helps to reduce mortality, morbidity, improve rehabilitation and patient flow within the NHS pathways. A guideline has been published to aid opiate prescription in elderly patients.

Assessment of drug-prescribing perception and practice among dental care providers: a cross-sectional Lebanese study.

Background:Dentists play an essential role in providing high-quality dental care, taking into consideration the clinical context and concomitant medications taken by the patients.Objective:This study aimed to assess drug-prescribing perception and practices in addition to drug-related educational needs among Lebanese dentists; it also evaluated the need for interprofessional collaboration between dentists and pharmacists.Methods:An exploratory cross-sectional study using an online questionnaire targeted a sample of dentists from all Lebanese districts. Participants gave their consent by accepting to complete the survey (ethics approval reference: USJ-2016-63). The questionnaire consisted of closed-ended questions exploring: 1) drug-prescribing perception, 2) drug-prescribing practice, and 3) collaboration with pharmacists regarding their respective roles in providing appropriate counseling to patients. Two indexes were created: the first evaluated self-confidence in prescribing medications, and the second assessed dentists’ confidence in pharmacists. Logistic regressions were performed, taking each index as a dependent variable.ResultsA total of 137 dentists completed the survey (59% females; mean age: 42.17; SD: 13.78 years). The majority had a fair to good perceived knowledge in pharmacology and therapeutics (80.3%), only 30.7% reported to be sufficiently equipped to prescribe safely. Dentists exhibited particularly low perceived knowledge about prescribing in elderly patients, dosing, medication use in pregnancy, drug interactions, and adverse reactions. Dentists specialized in periodontics had the lowest odds of having self-confidence in prescribing drugs (aOR=0.25; p<0.001). Also, 64.3% declared that they routinely check a reference source before prescribing, and 78% relied on pharmaceutical companies and medical representatives to get information on medications. While 61% declared that pharmacists should provide oral care counseling, only half of them encouraged their patients to talk to their pharmacists about their medications. Only 15% considered that patients are getting enough counseling from the pharmacist, with a global confidence index below the median value, suggesting the need for more collaboration, especially with periodontists who exhibited the lowest confidence in pharmacists (aOR=0.45).ConclusionsLebanese dentists reported some lack of knowledge and confidence in prescribing practices. Education, training, and close collaboration between pharmacists and dentists are essential to overcome these problems and avoid potential harm to patients.

Analysis of inappropriate prescribing in elderly patients of the Swiss HIV Cohort Study reveals gender inequity.

The extent of inappropriate prescribing observed in geriatric medicine has not been thoroughly evaluated in people ageing with HIV. We determined the prevalence of and risk factors for inappropriate prescribing in individuals aged ≥75 years enrolled in the Swiss HIV Cohort Study. Retrospective review of medical records was performed to gain more insights into non-HIV comorbidities. Inappropriate prescribing was screened using the Beers criteria, the STOPP/START criteria and the Liverpool drug-drug interactions (DDIs) database. For 175 included individuals, the median age was 78 years (IQR 76-81) and 71% were male. The median number of non-HIV comorbidities was 7 (IQR 5-10). The prevalence of polypharmacy and inappropriate prescribing was 66% and 67%, respectively. Overall, 40% of prescribing issues could have deleterious consequences. Prescribing issues occurred mainly with non-HIV drugs and included: incorrect dosage (26%); lack of indication (21%); prescription omission (drug not prescribed although indicated) (17%); drug not appropriate in elderly individuals (18%) and deleterious DDIs (17%). In the multivariable logistic regression, risk factors for prescribing issues were polypharmacy (OR: 2.5; 95% CI: 1.3-4.7), renal impairment (OR: 2.7; 95% CI: 1.4-5.1), treatment with CNS-active drugs (OR: 2.1; 95% CI: 1.1-3.8) and female sex (OR: 8.3; 95% CI: 2.4-28.1). Polypharmacy and inappropriate prescribing are highly prevalent in elderly people living with HIV. Women are at higher risk than men, partly explained by sex differences in the occurrence of non-HIV comorbidities and medical care. Medication reconciliation and periodic review of prescriptions by experienced physicians could help reduce polypharmacy and inappropriate prescribing in this vulnerable, growing population.

Positive impact of clinical pharmacist interventions on antipsychotic use in patients on excessive polypharmacy evidenced in a retrospective cohort study

Objectives Although antipsychotic prescribing in elderly patients using polypharmacy has not been studied in well-designed clinical trials and meta-analyses, there is an urgent need to monitor prescribing practice in this population. One of the possible approaches to optimize pharmacotherapy may be the involvement of clinical pharmacists (CPs). The aim of this research was to examine whether the involvement of a CP can improve treatment guidelines adherence and change the total number of medications per patient in older patients who are treated with excessive polypharmacy that includes antipsychotics. Methods This cohort retrospective study included older patients (65 years or older) treated with at least one antipsychotic and excessive polypharmacy (10 or more medications concurrently) between 2012 and 2014 in primary care. The main outcome measures were antipsychotic treatment guidelines’ adherence and the total number of medications per patient after the CP’s interventions. Only interventions including antipsychotics were studied in detail (i.e., discontinuation, switching, initiation, dose adjustment, change of another medication because of a drug-related problem). Data on diagnoses, patient pharmacotherapy and the CP’s interventions were obtained from clinical records and medical reviews. Age and acceptance of the CP’s interventions were used as predictive factors for antipsychotic treatment guidelines’ adherence. Results Forty-nine patients were included. The CP suggested 21 different interventions of which nine (42.8%) were accepted by the general practitioners. The number of medications that patients received decreased after the CP’s interventions (N of medications before: 15.4; N of medications after: 12.0, p < 0.05). The acceptance of the CP’s recommendations, but not age, improved antipsychotic treatment guidelines’ adherence (p = 0.041). Conclusions These results show that a collaborative care approach including a CP in primary care significantly improved the adherence to treatment guidelines. The results also support the implementation of this service in the Slovenian healthcare system, although more studies are needed.