Too much, too late? Drug prescribing for older people near the end of life

Background. The burden of drugs prescribed to older persons at the end of life has recently drawn increasing scrutiny. Growing evidence suggests that patients with lifelimiting diseases and poor prognosis are prescribed drugs that may do more harm than good or treatments that have little chance of achieving their benefit during the patients’ short remaining lifespan. The overall aim of this thesis was to evaluate the quality of drug prescribing in older adults near the end of life. Except for Study III, all studies are based on routinely collected administrative and healthcare data with national coverage in Sweden. Study I. We found that, throughout their last year of life, older adults (n=511 843) used an increasing number of prescription drugs. The proportion of older adults exposed to ≥10 drugs increased from 30.3% one year before death to 47.2% during the last month of life. Polypharmacy was fuelled not only by the initiation of symptomatic drugs to ensure comfort but also by the frequent continuation of long-term preventive treatments and medicines prescribed for the management of chronic diseases that may otherwise lead to short-term complications. Study II. Older adults who died with solid cancer (n=151 201) often continued to receive preventive drugs until the very end of life. Over the course of the last 12 months of life, there was little change in the receipt of antihypertensive agents (absolute change -0.3%, 95% CI -0.6 to 0.0), vitamin K antagonists (+1.5%, 95% CI 1.1 to 1.9), antiplatelet agents (- 1.5%, 95% CI -1.8 to -1.2), statins (-4.7%, 95% CI -5.0 to -4.4), bisphosphonates (-0.3%, 95% CI -0.4 to -0.2), or vitamins (+1.0, 95% CI 0.8 to 1.2). During the last year before death, median drug costs amounted to $1482 (interquartile range [IQR],$700-$2896]) per person, including$213 (IQR, $77-$490) for preventive therapies. We found important differences between cancer types with regard to the use and costs of preventive drugs, which can be explained only in part by age and chronic multimorbidity. Study III. Forty European experts in geriatrics, clinical pharmacology, and palliative medicine from 10 different countries participated in a Delphi consensus panel to identify drugs deemed “often adequate”, “questionable”, or “often inadequate” for use in older patients aged ≥75 years with an estimated life expectancy of 3 months or less. Drug classes rated as “often adequate” are predominantly indicated for symptom management and comfort care. Among the drugs and drug classes considered “questionable” for use near the end of life, a vast majority are prescribed for the longterm management of non-life-threatening chronic conditions or for the secondary prevention of chronic diseases that may otherwise quickly lead to serious clinical complications. Finally, drugs defined as “often inadequate” encompasses mostly drugs and supplements prescribed for primary prevention or as part of a long-term strategy of secondary or tertiary prevention. Study IV. By applying the list mentioned above to a cohort of 58 415 older persons who died from conditions potentially amenable to palliative care in 2015, we found that 32% continued and 14% initiated at least one drug considered “often inadequate” during their last three months of life. Excluding older adults who died from acute and potentially unpredictable fatal events had little if any influence on the results. Conclusion. Older people are prescribed an increasing number of drugs as they approach the end of life. A sizeable fraction of these drugs is not directed towards the relief of distressing symptoms but instead aims at prolonging survival and managing chronic comorbidities. We have developed a consensus-based set of explicit criteria for delineating drugs that are “often adequate” from those deemed “questionable” or “often inadequate” for use in older persons at the end of life. In the absence of high-quality data from randomised clinical trials and sufficiently robust observational studies, these criteria can be used not only to provide guidance at the bedside but also to generate comparable epidemiological evidence across patient groups, care settings, regions, and countries

New Bounds for Facial Nonrepetitive Colouring

We prove that the facial nonrepetitive chromatic number of any outerplanar graph is at most 11 and of any planar graph is at most 22.Comment: 16 pages, 5 figure

How chronic is polypharmacy in old age? A longitudinal nationwide cohort study

OBJECTIVE: To evaluate the chronicity of polypharmacy among older adults, and to identify factors associated with chronic polypharmacy. DESIGN: Longitudinal cohort study using register data. SETTING: Nationwide, Sweden. PARTICIPANTS: All 711,432 older adults (≥65 years) living in Sweden with 5 or more prescription drugs in October 2010 were included and followed-up until December 2013. Mean age at baseline was 77 (SD, 7.8) years, 59% were women, and 7% lived in nursing homes. MEASUREMENT: Monthly changes in the exposure to polypharmacy. Data regarding prescription drug use were extracted from the Swedish Prescribed Drugs Register. RESULTS: Overall, 82% were continuously exposed to polypharmacy during ≥6 months, and 74% during ≥12 months. The proportion of individuals who remained exposed until the end of the study was 55%. Among the 21,361 individuals who had not been exposed to polypharmacy during the 6-month period before baseline (i.e. with a new episode of polypharmacy), only 30% remained exposed for ≥6 months. The proportion of older adults who spent at least 80% of their follow-up time with polypharmacy was substantially higher among prevalent polypharmacy users at baseline than among those with a new polypharmacy episode (80% vs 24%, p<0.01). Factors associated with chronic polypharmacy included higher age, female gender, living in an institution, chronic multimorbidity, and multi-dose dispensing. CONCLUSION: Polypharmacy is most often chronic, although a substantial share of older adults experience short, recurring episodes of polypharmacy and are thus exposed to its potential harms in a transient rather than persistent manner.Swedish Research Council (2015-03618)Accepte

Modeling and simulation of laser shock waves in elasto-plastic polycrystalline microstructures

We study the propagation of elasto-plastic shockwaves induced by high power laser impacts in 2D polycrystalline metallic alloys in order to investigate the influence of the material microstructure on the fields of plastic strain and subsequent residual stresses. Implementing a visco-plastic constitutive relation at the grain scale accounting for two dislocation slip systems into a finite volume numerical scheme, simulations on single crystal specimens with different lattice orientations show that plastic strain is concentrated in narrow bands originating at the edges of the laser impact and parallel to the slip planes. In the case of polycrystalline microstructures composed of randomly oriented grains, it is found that the microstructure morphology is the origin of a heterogeneous distribution of the residual plastic strain and stress fields, which thus departs from the residual stress fields usually modeled when the microstructure is not accounted for. To account for the random character of polycrystal microstructures, we perform a statistical analysis of the mechanical fields over a large number of microstructures to quantify the dispersion of the results. It is found that even though the residual stresses induced by a laser impact are in compression on average at the center of the laser impact, some realizations of the microstructures can lead to localized concentrations of less compressive, or even tensile, residual stresses at the surface, thus probably reducing the fatigue resistance of the shocked material

Heavy alcohol consumption before and after negative life events in late mid-life : longitudinal latent trajectory analyses

Background People who experience negative life events report more heavy alcohol consumption compared with people without these experiences, but little is known about patterns of change within this group. This study aims to identify trajectories of heavy alcohol consumption before and after experiencing either divorce, or severe illness or death in the family. Furthermore, the aim is to examine characteristics of individuals belonging to each trajectory. Methods Longitudinal study of public sector employees from the Finnish Retirement and Aging Study with up to 5 years of annual follow-ups (n=6783; eligible sample n=1393). Divorce and severe illness or death in the family represented negative life events. Heavy alcohol consumption was categorised as >14 units/week. Results Based on latent trajectory analysis, three trajectories of heavy drinking were identified both for divorce and for severe illness or death in the family: 'No heavy drinking' (82% illness/death, 75% divorce), 'Constant heavy drinking' (10% illness/death, 13% divorce) and 'Decreasing heavy drinking' (7% illness/death, 12% divorce). Constant heavy drinkers surrounding illness or death in the family were more likely to be men, report depression and anxiety and to smoke than those with no heavy drinking. Constant heavy drinkers surrounding divorce were also more likely to be men and to report depression compared with those with no heavy drinking. Conclusions Most older workers who experience divorce or severe illness or death in the family have stable drinking patterns regarding heavy alcohol consumption, that is, most do not initiate or stop heavy drinking.Peer reviewe

Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study

Abstract Background The burden of medications near the end of life has recently come under scrutiny, because several studies suggested that people with life-limiting illness receive potentially futile treatments. Methods We identified 511,843 older adults (>65 years) who died in Sweden between 2007 and 2013 and reconstructed their drug prescription history for each of the last 12 months of life through the Swedish Prescribed Drug Register. Decedents' characteristics at time of death were assessed through record linkage with the National Patient Register, the Social Services Register, and the Swedish Education Register. Results Over the course of the final year before death, the proportion of individuals exposed to ≥10 different drugs rose from 30.3% to 47.2% ( P Conclusion Polypharmacy increases throughout the last year of life of older adults, fueled not only by symptomatic medications but also by long-term preventive treatments of questionable benefit. Clinical guidelines are needed to support physicians in their decision to continue or discontinue medications near the end of life

La bioadsorption sur amidon réticulé pour enlever des métaux des effluents industriels

L’industrie de traitement de surface utilise de nombreux produits chimiques, en particulier des métaux toxiques et des substances organiques, qui sont connus pour être nocifs vis-à-vis des humains et de l’environnement. En raison d’une réglementation de plus en plus stricte, les effluents contenant des métaux lourds doivent être traités. Il existe une grande variété de procédés de traitement des eaux usées provenant de la filière traitement de surface. En général, les systèmes conventionnels de détoxification se composent principalement d’un ajustement de pH, d’une oxydation des cyanures et d’une réduction des chromes, suivi d’une précipitation sous forme d’hydroxydes et d’une clarification, et parfois d’une étape d’adsorption sur charbon. Cependant, la technologie sur charbon actif présente plusieurs problèmes tels que la saturation rapide et des problèmes de colmatage des réacteurs. Comme les résines d'échange d’ions, leur utilisation est restreinte due au coût élevé. Pour ces raisons, la plupart des petites et moyennes entreprises ne peuvent pas utiliser de tels traitements. Ainsi, afin de répondre à ces problématiques, de nombreuses études sont menées pour trouver des alternatives peu coûteuses, qui soient efficaces et acceptables pour un usage industriel. Dans cette étude, la bioadsorption sur un adsorbant d’amidon réticulé a été utilisée pour retenir les métaux contenus dans des effluents industriels. L’adsorption a été étudiée en fonction du temps de contact, de la masse d’adsorbant et de la charge polluante. L’influence de ces paramètres sur l’efficacité d’adsorption a été évaluée en utilisant une méthode conventionnelle en mode cuvée. Les résultats ont montré que le matériau présente des capacités d’adsorption élevées vis-à-vis des ions métalliques, ce qui permet de diminuer les concentrations métalliques en dessous des valeurs réglementaires. Des mesures de taux de germination sur des graines de Lactuca sativa, utilisé comme test de phytotoxicité, ont été réalisées sur les rejets industriels avant et après adsorption. Ces tests ont confirmé l’efficacité du procédé pour diminuer fortement la toxicité du rejet. L’abattement chimique et la réduction de la toxicité ont montré que la bioadsorption sur un matériau non conventionnel peut être une étape de finition intéressante pour la détoxification des rejets industriels.The surface-treatment industry consumes and discharges an important range of chemicals, in particular toxic metals and organics, that are known to be harmful to humans and the environment. Because of more and more stringent regulations, effluents polluted with heavy metals must be treated. There are a variety of treatment processes for wastewater from the surface-treatment industry. In general, conventional treatment and detoxification systems consist mainly of pH adjustments, oxidation of cyanide and reduction of chromium bearing wastewaters, followed by hydroxide precipitation, clarification, and sometimes carbon sorption. However, active carbon technology presents several problems such as rapid saturation and clogging of the reactors. Like ion-exchange resins, their widespread use is restricted due to high cost. For these reasons, most small and medium-size enterprises cannot employ such treatments. Thus, in order to overcome these problems, many attempts have been made to find inexpensive alternative sorbents, which are both effective and acceptable for industrial use. In this study, biosorption with a starch-based cross-linked adsorbent was used for the removal of heavy metals from industrial effluents. The adsorption of metals was studied as a function of contact time, adsorbent mass and pollutant load. The influence of these parameters on the adsorption efficiency was evaluated using a conventional batch method. Batch experiments showed that the material exhibited high sorption capacities toward metal ions, leading to concentrations that were below current regulatory values. Measurements of the germination rate of Lactuca sativa seeds, used as a phytotoxicity test, were carried out on discharged industrial waters before and after the finishing sorption treatment. Germination tests confirmed the ability of the sorption step to radically decrease the effluent toxicity. Both the chemical abatement and toxicity mitigation of waste water showed that biosorption onto a non-conventional sorbent may constitute an interesting additional treatment step for the detoxification of industrial wastewater

Use of artificial nutrition near the end of life: Results from a French national population-based study of hospitalized cancer patients

International audienceBackgroundThe use of artificial nutrition, defined as a medical treatment that allows a non‐oral mechanical feeding, for cancer patients with limited life expectancy is deemed nonbeneficial. High‐quality evidence about the use of artificial nutrition near the end of life is lacking. This study aimed (a) to quantify the use of artificial nutrition near the end‐of‐life, and (b) to identify the factors associated with the use of artificial nutrition.MethodsThis was a retrospective cohort study of decedents based on data from the French national hospital database. The study population included adult cancer patients who died in hospitals in France between 2013 and 2016 and defined to be in a palliative condition. Use of artificial nutrition during the last 7 days before death was the primary endpoint.ResultsA total of 398 822 patients were included. The median duration of the last hospital stay was 10 (interquartile range, 4‐21) days. The artificial nutrition was used for 11 723 (2.9%) during the last 7 days before death. Being a man, younger, having digestive cancers, metastasis, comorbidities, malnutrition, absence of dementia, and palliative care use were the main factors associated to the use of artificial nutrition.ConclusionThis study indicates that the use of artificial nutrition near the end of life is in keeping with current clinical guidelines. The identification of factors associated with the use of artificial nutrition, such as cancer localization, presence of comorbidities or specific symptoms, may help to better manage its use

Exact expressions of the uniaxial perfectly elasto-plastic stress wave and induced mechanical fields in the case of a finite impact: application to laser shock peening

This paper aims at providing exact expressions for the mechanical fields induced by Laser Shock Peening and comparing them to their numerical estimations. We use a uniaxial strain field hypothesis with an elastic perfectly plastic behavior to derive the stress wave equation. An exact solution to this equation is given using the method of characteristics for a step time profile for the pressure loading, and numerically using finite differences schemes adapted for this hyperbolic equation. An additional residual stress modeling is used, providing the residual stress distribution assuming a planar infinite plate with a finite thickness. Results are presented for three loading pressures, each one corresponding to a different structure in the exact solution. The exact and numerical results present a good match, allowing either the use of the exact solution for an initial estimation of the mechanical fields, or to test the accuracy of other numerical methods. © 2023 Elsevier Masson SAS. All rights reserve