Drug Treatment in Older People before and after the Transition to a Multi-Dose Drug Dispensing System - A Longitudinal Analysis

Tverrsnittstudie, undersøker assosiasjonen mellom multidose og polyfarmasi hos eldre.Background: an association has been found between multi-dose drug dispensing (MDD) and use of many drugs. The aim of this study was to investigate the nature of this association, by performing a longitudinal analysis of the drug treatment before and after the transition to MDD. Methods: inclusion critera in this register-based study were inhabitants in Region Västra Götaland, Sweden, who, at ≥65 years of age and between 1st July 2006 and 30th June 2010, filled their first MDD prescription. For each individual, prescribed drugs were estimated at three month intervals before and after (maximum 3 years, respectively) the first date of filling an MDD prescription (index date). Results: a total of 30,922 individuals matched the inclusion criteria (mean age: 83.2 years; 59.9% female). There was a temporal association between the transition to MDD and an increased number of drugs: 5.463.9 and 7.563.8 unique drugs three months before and after the index date, respectively, as well as worse outcomes on several indicators of prescribing quality. When either data before or after the index date were used, a multi-level regression analysis predicted the number of drugs at the index date at 5.76 (95% confidence limits: 5.71; 5.80) and 7.15 (7.10; 7.19), respectively, for an average female individual (83.2 years, 10.8 unique diagnoses, 2.4 healthcare contacts/three months). The predicted change in the number of drugs, from three months before the index date to the index date, was greater when data before this date was used as compared with data after this date: 0.12 (0.09; 0.14) versus 0.02 (20.01; 0.05). Conclusions: after the patients entered the MDD system, they had an increased number of drugs, more often potentially harmful drug treatment, and fewer changes in drug treatment. These findings support a causal relationship between such a system and safety concerns as regards prescribing practices

Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus

This is the author accepted manuscript. The final version is available from Wiley via the DOI in this record.The complexity and heterogeneity of patients with multimorbidity and polypharmacy renders traditional disease-oriented guidelines often inadequate and complicates clinical decision making. To address this challenge, guidelines have been developed on multimorbidity or polypharmacy. To systematically analyse their recommendations, we conducted a systematic guideline review using the Ariadne principles for managing multimorbidity as analytical framework. The information synthesis included a multistep consensus process involving 18 multidisciplinary experts from seven countries. We included eight guidelines (four each on multimorbidity and polypharmacy) and extracted about 250 recommendations. The guideline addressed (i) the identification of the target population (risk factors); (ii) the assessment of interacting conditions and treatments: medical history, clinical and psychosocial assessment including physiological status and frailty, reviews of medication and encounters with healthcare providers highlighting informational continuity; (iii) the need to incorporate patient preferences and goal setting: eliciting preferences and expectations, the process of shared decision making in relation to treatment options and the level of involvement of patients and carers; (iv) individualized management: guiding principles on optimization of treatment benefits over possible harms, treatment communication and the information content of medication/care plans; (v) monitoring and follow-up: strategies in care planning, self-management and medication-related aspects, communication with patients including safety instructions and adherence, coordination of care regarding referral and discharge management, medication appropriateness and safety concerns. The spectrum of clinical and self-management issues varied from guiding principles to specific recommendations and tools providing actionable support. The limited availability of reliable risk prediction models, feasible interventions of proven effectiveness and decision aids, and limited consensus on appropriate outcomes of care highlight major research deficits. An integrated approach to both multimorbidity and polypharmacy should be considered in future guidelines.Journal of Internal MedicineKarolinska Institutet Strategic Research Area in Epidemiology (SfoEpi

Adherence to a femoral neck fracture treatment guideline

Purpose: In 2007 the Dutch Surgical Society published a clinical practice guideline for the treatment of hip fracture patients, based on the best available international evidence at that time. We investigated to what extent treatment of femoral neck fracture patients in the Netherlands corresponded with these guidelines, and determined differences in patient characteristics between the treatment groups. Methods: All femoral neck fracture patients treated in 14 hospitals between February 2008 and August 2009 were included. Patient characteristics, X-rays, and treatment data were collected retrospectively. Results: From a total of 1,250 patients 59 % had been treated with arthroplasty, 39 % with internal fixation, and 2 % with a non-operative treatment. While 74 % of the treatment choices complied with the guideline, 12 % did not. In 14 % adherence could not be determined from the available data. Arthroplasty was preferred over internal fixation in elderly patients with severe comorbidity, pre-fracture osteoporosis and a displaced fracture, who were ambulatory with aids pre-fracture (odds ratio, OR 2.2-58.1). Sliding hip screws were preferred over cancellous screws in displaced fractures (OR 1.9). Conclusions: Overall guideline adherence was good. Most deviations concerned treatment of elderly patients with a displaced fracture and implant use in internal fixation. Additional data on these issues, preferably at a higher scientific level of evidence, is needed in order to improve the guideline and to reinforce a more uniform treatment of these patients

Determinants of fracture risk in a UK-population-based cohort of older women: a cross-sectional analysis of the Cohort for Skeletal Health in Bristol and Avon (COSHIBA)

Background: identification of individuals with high fracture risk from within primary care is complex. It is likely that the true contribution of falls to fracture risk is underestimated

Timing of Subsequent Fractures after an Initial Fracture

A prior fracture is a well-documented risk factor for a subsequent fracture and it doubles the risk of subsequent fractures. Few studies have investigated the time that elapses between the initial and subsequent fracture. These studies show that the subsequent fracture risk is not constant, but fluctuates over time. The risk of subsequent vertebral, hip, and nonvertebral non-hip fractures is highest immediately after initial hip, clinical, and radiographic vertebral fractures and nonvertebral fractures and declines afterward, regardless of gender, age, and initial fracture location. These studies indicate the need for early action after an initial fracture with medical interventions that have an effect within a short term to reduce the preventable risks of subsequent fractures

Dopaminergic and Serotonergic Drug Use: A Nationwide Register-Based Study of Over 1 300 000 Older People

OBJECTIVE: To investigate the use of dopaminergic and serotonergic drugs in elderly people. METHODS: We analyzed data on age, sex and dispensed drugs for individuals aged ≥65 years registered in the Swedish Prescribed Drug Register from July to September 2008 (n = 1,347,564; 81% of the total population aged ≥65 years in Sweden). Main outcome measures were dopaminergic (enhancing and/or lowering) and serotonergic (enhancing and/or lowering) drugs and combinations of these. RESULTS: Dopaminergic and serotonergic drugs were used by 5.6% and 13.2% the participants, respectively. Female gender was related to use of both dopaminergic and, particularly, serotonergic drugs. Higher age was associated with use of dopamine lowering drugs and serotonergic drugs, whereas the association with use of dopamine enhancing drugs declined in the oldest old. The occurrence of combinations of dopaminergic and serotonergic drugs was generally low, with dopamine lowering + serotonin lowering drug the most common combination (1.6%). Female gender was associated with all of the combinations of dopaminergic and serotonergic drugs, whereas age showed a mixed pattern. CONCLUSION: Approximately one out of ten older patients uses serotonergic drugs and one out of twenty dopaminergic drugs. The frequent use of dopaminergic and serotonergic drugs in the elderly patients is a potential problem due to the fact that aging is associated with a down-regulation of both these monoaminergic systems. Future studies are needed for evaluation of the impact of these drugs on different cognitive and emotional functions in old age

Dopaminergic and Serotonergic Drug Use: A Nationwide Register-Based Study of Over 1 300 000 Older People

Objective: To investigate the use of dopaminergic and serotonergic drugs in elderly people. Methods: We analyzed data on age, sex and dispensed drugs for individuals aged $65 years registered in the Swedish Prescribed Drug Register from July to September 2008 (n = 1 347 564; 81$65 years in Sweden). Main outcome measures were dopaminergic (enhancing and/or lowering) and serotonergic (enhancing and/or lowering) drugs and combinations of these. Results: Dopaminergic and serotonergic drugs were used by 5.6 % and 13.2 % the participants, respectively. Female gender was related to use of both dopaminergic and, particularly, serotonergic drugs. Higher age was associated with use of dopamine lowering drugs and serotonergic drugs, whereas the association with use of dopamine enhancing drugs declined in the oldest old. The occurrence of combinations of dopaminergic and serotonergic drugs was generally low, with dopamine lowering + serotonin lowering drug the most common combination (1.6%). Female gender was associated with all of the combinations of dopaminergic and serotonergic drugs, whereas age showed a mixed pattern. Conclusion: Approximately one out of ten older patients uses serotonergic drugs and one out of twenty dopaminergic drugs. The frequent use of dopaminergic and serotonergic drugs in the elderly patients is a potential problem due to the fact that aging is associated with a down-regulation of both these monoaminergic systems. Future studies are needed fo

The World Hip Trauma Evaluation Study 3 HEMIARTHROPLASTY EVALUATION BY MULTICENTRE INVESTIGATION - WHiTE 3: HEMI - AN ABRIDGED PROTOCOL

Approximately half of all hip fractures are displaced intracapsular fractures. The standard treatment for these fractures is either hemiarthroplasty or total hip arthroplasty. The recent National Institute for Health and Care Excellence (NICE) guidance on hip fracture management recommends the use of 'proven' cemented stem arthroplasty with an Orthopaedic Device Evaluation Panel (ODEP) rating of at least 3B (97% survival at three years). The Thompsons prosthesis is currently lacking an ODEP rating despite over 50 years of clinical use, likely due to the paucity of implant survival data. Nationally, adherence to these guidelines is varied as there is debate as to which prosthesis optimises patient outcomes.This study design is a multi-centre, multi-surgeon, parallel, two arm, standard-of-care pragmatic randomised controlled trial. It will be embedded within the WHiTE Comprehensive Cohort Study (ISRCTN63982700). The main analysis is a two-way equivalence comparison between Hemi-Thompson and Hemi-Exeter polished taper with Unitrax head. Secondary outcomes will include radiological leg length discrepancy measured as per Bidwai and Willett, mortality, re-operation rate and indication for re-operation, length of index hospital stay and revision at four months. This study will be supplemented by the NHFD (National Hip Fracture Database) dataset.Evidence on the optimum choice of prosthesis for hemiarthroplasty of the hip is lacking. National guidance is currently based on expert opinion rather than empirical evidence. The incidence of hip fracture is likely to continue to increase and providing high quality evidence on the optimumCite this article: A. L. Sims. The World Hip Trauma Evaluation Study 3: Hemiarthroplasty Evaluation by Multicentre Investigation - WHITE 3: HEMI - An Abridged Protocol. Bone Joint Res 2016;5:18-25. doi: 10.1302/2046-3758.51.2000473

Lower prevalence of hip fractures in foreign-born individuals than in Swedish-born individuals during the period 1987-1999

<p>Abstract</p> <p>Background</p> <p>This is the first longitudinal study with a 22-year follow-up, based on a national and complete sample, to determine whether the prevalence of hip fracture and the age when it occurs are influenced by migration and by being foreign-born. Cultural background and environmental factors such as UV-radiation and lifestyle during childhood and adolescence may influence the risk of a hip fracture event later in life. Differences in prevalence might occur between the indigenous population and those who have migrated to a country.</p> <p>Methods</p> <p>The study was based on national population data. The study population consisted of 321,407 Swedish-born and 307,174 foreign-born persons living in Sweden during the period 1987-1999.</p> <p>Results</p> <p>Foreign-born individuals had a reduced risk of hip fracture, with odds ratios (ORs) of 0.47-0.77 for men and 0.42-0.88 for women. Foreign-born women had the hip fracture event at a higher age on average, but a longer time spent in Sweden was associated with a small but significant increase in risk.</p> <p>Conclusions</p> <p>We found that there was a reduced risk of hip fracture in all foreign-born individuals, and that the hip fracture event generally happened at a higher age in foreign-born women. Migration must therefore be considered in relation to the prevalence and risk of hip fracture. Migration can therefore have a positive effect on one aspect of the health of a population, and can influence and lower the total cost of healthcare due to reduced risk and prevalence of hip fracture.</p

Periferne osteoporotske frakture osim kuka - epidemiologija i značenje

Fractures are the most serious consequence of osteoporosis. Non-vertebral and non-hip fractures are seldom recognised as important, even though they account for the majority of all fractures. The most prevalent localisations are distal radius, proximal humerus, ribs, clavicle, and the pelvis. According to the results from large phase III clinical trials for placebo groups, their incidence ranges from 4.9 % to 12.0 %. Hospital morbidity data in Croatia in 2006 show that peripheral non-hip fractures ranked among the leading fifteen injuries, accounting for 23.7 % of all injuries in patients aged 60 years and above. Risk factors for non-hip and non-vertebral fractures are similar to other osteoporotic fractures, and the main are low bone mineral density and earlier fractures. Quality of life is considerably affected by these fractures, and medical costs are very high, soaring as high as 36.9 % of all national medical costs in the USA. Nonvertebral non-hip fractures need more attention, which was also recognised by the European regulatory bodies that approve use of anti-osteoporotic drugs.Prijelomi su najozbiljnija posljedica osteoporoze. Iako čine većinu svih fraktura, nevertebralne frakture osim kuka rijetko se prepoznaju kao značajne. Najčešće lokalizacije tih prijeloma su: distalni dio radijusa, proksimalni dio humerusa, rebra, klavikula i zdjelica. Prema rezultatima iz placebo-grupa III. faze velikih kliničkih ispitivanja raspon njihove incidencije iznosi između 4,9 % i 12,0 %. Prema podacima bolničkog pobolijevanja za 2006. g. u Hrvatskoj, među 15 vodećih ozljeda u dobnoj grupi 60 i više godina 23,7 % bile su periferne frakture osim kuka. Čimbenici rizika za nevertebralne frakture osim onih kuka slični su kao i za druge osteoporotske frakture gdje središnje mjesto imaju niska mineralna gustoća kosti i prethodne frakture. Ove frakture imaju velik utjecaj na kvalitetu `ivota, a njihovi su troškovi vrlo visoki, tako da u SAD-u iznose čak 36.9 % svih nacionalnih medicinskih troškova. Nevertebralne frakture osim kuka zahtijevaju veću pozornost, što su i prepoznala europska regulatorna tijela koja odobravaju upotrebu antiosteoporotskih lijekova