Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis: a prospective cohort study

Purpose We aimed to study the use of The 4 ‘A’s test (4AT), a rapid delirium screening tool, performed upon Emergency Department (ED) admission, and to characterize older patients admitted to the ED with and without sepsis in terms of delirium features. Methods In this prospective cohort study, we included patients aged ≥ 65 years, admitted to the ED with suspected sepsis. ED nurses and doctors performed delirium screening with 4AT within two hours after ED admission, and registered the time spent on the screening in each case. Sepsis and delirium during the hospital stay were diagnosed retrospectively, according to recommended diagnosis criteria. Results Out of the 196 patients included (mean age 81 years, 60% men), 100 patients fulfilled the sepsis diagnosis criteria. The mean 4AT screening time was 2.5 Minutes. In total, 114 patients (58%) had a 4AT score ≥ 1, indicating cognitive impairment, upon ED admission. Sepsis patients more often had a 4AT score ≥ 4, indicating delirium, than patients without sepsis (40% vs. 26%, p < 0.05). Out of the 100 patients with sepsis, 68 (68%) had delirium during the hospital stay, as compared to 34 out of 96 patients (35%) without sepsis (p < 0.05). Conclusion Delirium screening upon ED admission, using 4AT, was feasible among patients aged ≥ 65 years admitted with suspected sepsis. Two out of three patients had at least one feature of delirium upon admission. The prevalence of delirium during the hospital stay was high, particularly in patients with sepsis.publishedVersio

START OG STOPP versjon 2. Screeningverktøy for forskrivning av legemidler til eldre

Screeningverktøy for forskrivning av legemidler til eldre. Validert for norske forhold av Norsk Geriatrisk Forening

Teaching geriatric medicine through gamification: a tool for enhancing postgraduate education in geriatric medicine

Background Polypharmacy is becoming increasingly common and all doctors must be prepared to manage it competently. Aims The aim of this project is to evaluate the feasibility and use of a novel gamification-based teaching intervention on polypharmacy among doctors undergoing advanced geriatric training. Among others, one of the learning goals for the students was to be able to describe the adherence to medication. Methods Electronic questionnaire sent to students of the third session “evidence-based medicine in geriatrics” of advanced postgraduate course in geriatrics of the European Academy for Medicine of Ageing. Results Most students reported issues with forgetting doses and remembering sufficiently to establish a medication routine due to busy schedules as well as social influences around medication taking. Reflecting on the challenges of the game, most students reported that their own prescribing practice was likely to change. Discussion and conclusion The current model of learning appears to be a feasible approach for postgraduate medical education or in other areas of healthcare such as nursing or physiotherapy. Learning through action and reflection promotes deeper thinking and can lead to behavioral change, in this case thus enhancing the attitudes and understanding regarding pharmacological issues associated with ageing. Recommendations for future research in medical education about medication adherence are outlined.publishedVersio

A Systematic Review of the Current Evidence from Randomised Controlled Trials on the Impact of Medication Optimisation or Pharmacological Interventions on Quantitative Measures of Cognitive Function in Geriatric Patients

Publisher Copyright: © 2022, The Author(s).Background: Cognitive decline is common in older people. Numerous studies point to the detrimental impact of polypharmacy and inappropriate medication on older people’s cognitive function. Here we aim to systematically review evidence on the impact of medication optimisation and drug interventions on cognitive function in older adults. Methods: A systematic review was performed using MEDLINE and Web of Science on May 2021. Only randomised controlled trials (RCTs) addressing the impact of medication optimisation or pharmacological interventions on quantitative measures of cognitive function in older adults (aged > 65 years) were included. Single-drug interventions (e.g., on drugs for dementia) were excluded. The quality of the studies was assessed by using the Jadad score. Results: Thirteen studies met the inclusion criteria. In five studies a positive impact of the intervention on metric measures of cognitive function was observed. Only one study showed a significant improvement of cognitive function by medication optimisation. The remaining four positive studies tested methylphenidate, selective oestrogen receptor modulators, folic acid and antipsychotics. The mean Jadad score was low (2.7). Conclusion: This systematic review identified a small number of heterogenous RCTs investigating the impact of medication optimisation or pharmacological interventions on cognitive function. Five trials showed a positive impact on at least one aspect of cognitive function, with comprehensive medication optimisation not being more successful than focused drug interventions. More prospective trials are needed to specifically assess ways of limiting the negative impact of certain medication in particular and polypharmacy in general on cognitive function in older patients.Peer reviewe

Potentially inappropriate drug use and hip fractures among older people. Pharmacoepidemiological studies

Over the last decades there has been a major increase in the use of prescribed drugs, especially among older people. Although beneficial in many situations, the use of medications is also associated with potential harms. Older people are particularly vulnerable to adverse effects of drugs use, due to age- and disease-related changes, multimorbidity and (often) complex drug regimens. Psychotropic drugs are known to increase the risk of falling; hip fractures are feared consequences of falls, due to resulting loss of function, and high morbidity and mortality. This thesis is based on two empirical studies. Study I (paper I) investigates drug use and prescribing quality among acutely hospitalized older people. Study II (papers II and III) investigates associations between psychotropic drug use and hip fractures. Drug use and prescribing quality (study I) Aims: To identify inappropriate prescribing among older people (≥ 70) on acute hospital admission and on discharge from an intermediate-care nursing home unit (INHU) and hospital wards (HWs). Furthermore, to compare changes in inappropriate prescribing within and between these groups during stay. Methods: This was an observational study conducted among community-dwelling older people acutely admitted to hospitals in Bergen. The study population comprised 290 (157 transferred to the INHU, 133 treated in HWs) individuals. Drug use was obtained from medication charts. Results: Potentially inappropriate medicines (PIMs) and drug-drug interactions (DDIs) were prevalent among community-dwelling older people acutely admitted to hospital, and increased during stay in hospital or intermediate care nursing home. Concomitant use of several psychotropic drugs and inappropriate drug combinations including non-steroidal anti-inflammatory drugs (NSAIDs) were the PIMs most frequently identified. Serious DDIs were scarce. No reductions in number of drugs, PIMs or DDIs were identified in either setting. Psychotropic drugs and hip fractures (study II) Aims: To examine associations between exposure to antidepressant, anxiolytic or hypnotic drugs and the risk of hip fracture among older people; to examine associations between exposure to hypnotic drugs and the time of hip fracture; and to estimate the share of hip fractures attributable to exposure to antidepressant, anxiolytic and hypnotic drugs (attributable risk). Methods: A nationwide prospective cohort study based on merged data from three registries (the Norwegian Prescription Database, the Norwegian Hip Fracture Registry and the Central Population Registry) was conducted. The study population included all 906,422 individuals born prior to 1945 and living in Norway on study start, January 1, 2005. The study period ended on December 31, 2010. Results: Being exposed to any antidepressant, anxiolytic or hypnotic drug was associated with an excess risk of hip fracture as compared to non-exposure. Being exposed to selective serotonin reuptake inhibitors (SSRIs) and other drugs with high/intermediate serotonergic properties was associated with the greatest excess risk – which was almost 2-fold. We found no evidence that short-acting benzodiazepines (SABs) were safer than long-acting benzodiazepines with regards to hip fracture. People exposed to z-hypnotics were at greatest excess risk at night. The attributable risk of antidepressants was estimated at about 5% and anxiolytics and hypnotics at about 3%. At the population level this corresponds to more than 3000 fractures during the 6 year study period. Conclusion and implications: Study I revealed that inappropriate prescribing was common, increased regardless of setting, and frequently involved psychotropic drugs. In study II clinically relevant associations between widely used psychotropic drugs and the risk of hip fracture were identified. These findings imply that there is need for improving the drug treatment for older people, and that the recommended psychotropic drugs (SSRIs, SABs and zhypnotics) offer no advantages with regard to hip fractures as compared to the traditional alternatives

Inappropriate prescribing for older people admitted to an intermediate-care nursing home unit and hospital wards

Objective: To identify inappropriate prescribing among older patients on admission to and discharge from an intermediatecare nursing home unit and hospital wards, and to compare changes during stay within and between these groups. Design: Observational study. Setting and subjects: Altogether 400 community-dwelling people aged ≥ 70 years, on consecutive emergency admittance to hospital wards of internal medicine and orthopaedic surgery, were randomized to an intermediatecare nursing home unit or hospital wards; 290 (157 at the intermediate-care nursing home unit and 133 in hospital wards) were eligible for this sub-study. Main outcome measures: Prevalence on admission and discharge of potentially inappropriate medications (Norwegian general practice [NORGEP] criteria) and drug – drug interactions; changes during stay. Results: The mean (SD) age was 84.7 (6.2) years; 71% were women. From admission to discharge, the mean numbers of drugs prescribed per person increased from 6.0 (3.3) to 9.3 (3.8), p < 0.01. The prevalence of potentially inappropriate medications increased from 24% to 35%, p < 0.01; concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-infl ammatory drugs (NSAIDs) increased signifi cantly. Serious drug – drug interactions were scarce both on admission and discharge (0.7%). Conclusions: Inappropriate prescribing was prevalent among older people acutely admitted to hospital, and the prevalence was not reduced during stay at an intermediate-care nursing home unit specially designed for these patients

Risk of hip fracture among older people using anxiolytic and hypnotic drugs: a nationwide prospective cohort study

Purpose Anxiolytics and hypnotics are widely used and may cause injurious falls. We aimed to examine associations between exposure to anxiolytics and hypnotics and the risk of hip fracture among all older people in Norway. Further, we wanted to examine associations between exposure to hypnotics and time of fracture. Methods A nationwide prospective cohort study of people in Norway born before 1945 (n=906,422) was conducted. We obtained information on all prescriptions of anxiolytics and hypnotics dispensed in 2004–2010 (the Norwegian Prescription Database) and all primary hip fractures in 2005–2010 (the Norwegian Hip Fracture Registry). We compared the incidence rates of hip fracture during drug exposure and non-exposure by calculating the standardized incidence ratio (SIR). Results Altogether, 39,938 people (4.4 %) experienced a primary hip fracture. The risk of hip fracture was increased for people exposed to anxiolytics (SIR 1.4, 95 % confidence interval (CI) 1.4–1.5) and hypnotics (SIR 1.2, 95 % CI 1.1– 1.2); the excess risk was highest regarding short-acting benzodiazepine anxiolytics (SIR 1.5, 95 % CI 1.4–1.6). Benzodiazepine-like hypnotics (z-hypnotics) were associated with higher excess risk of hip fracture at night (SIR 1.3, 95 % CI 1.2–1.4) than during the day (SIR 1.1, 95 % CI 1.1–1.2). Conclusions Older people had an increased risk of hip fracture during anxiolytic or hypnotic drug use, including shortacting benzodiazepine anxiolytics and z-hypnotics that were previously considered less harmful; cautious prescribing is therefore needed. People using z-hypnotics were at greatest excess risk at night; this association deserves further investigation