Polypharmacy, inappropriate prescribing, and deprescribing in older people : through a sex and gender lens

Polypharmacy is very common in older adults and increases the risk of inappropriate and unsafe prescribing for older adults. Older adults, particularly women (who make up the majority of this age group), are at the greatest risk for drug-related harm. Therefore, optimising drug prescribing for older people is very important. Identifying potentially inappropriate medications and opportunities for judicious deprescribing processes are intrinsically linked, complementary, and essential for optimising medication safety. This Review focuses on optimising prescribing for older adults by reducing doses or stopping drugs that are potentially harmful or that are no longer needed. We explore how sex (biological) and gender (sociocultural) factors are important considerations in safe drug prescribing. We conclude by providing a practical approach to optimising medication safety that clinicians can routinely apply to the care of their older patients, highlighting how sex and gender considerations inform medication decision making

Non-pharmacological, non-surgical interventions for urinary incontinence in older persons : A systematic review of systematic reviews. The SENATOR project ONTOP series

This work was supported by the European Union Seventh Framework program (FP7/2007–2013) under grant agreement n° 305930Peer reviewedPostprin

Nonpharmacologic Management of Orthostatic Hypotension in Older People : A Systematic Review. The SENATOR ONTOP Series

The research leading to these results was supported by the European Union Seventh Framework Programme (FP7/2007–2013) under grant agreement no. 305930 (SENATOR project). The sponsor did not play any role in the study design, methods, data collection and analysis, and preparation of the article.Peer reviewedPostprin

Diabetes mellitus increases risk of adverse drug reactions and death in hospitalised older people : the SENATOR trial

Purpose: Adverse drug reactions (ADRs) are a major cause of morbidity and mortality, especially in older people. Older people with diabetes mellitus may be at especially high risk of ADRs but this risk has not been well studied. This study aimed to compare severity and type of ADRs in hospitalised, multimorbid older people with and without diabetes and secondly to assess the impact of ADRs on mortality, rehospitalisation and length of stay. Methods: Participants in the SENATOR (Software Engine for the Assessment and optimization of drug and non-drug Therapy in Older peRsons) trial were assessed for 12 common and ‘other’ prevalent and incident adverse drug reactions using a blinded end-point adjudication process. Descriptive analyses, logistic regression and mediation analyses were undertaken. Results: Of 1537 people in the SENATOR trial, 540 (35.1%) had diabetes mellitus (mean age 77.4 ± 7.3 years, 58.5% male). In the total population, 773 prevalent and 828 incident ADRs were reported. Both prevalent and incident symptomatic hypoglycaemia and incident acute kidney injury (AKI) were significantly more common in people with diabetes (p < 0.05). Patients with diabetes had higher all-cause mortality at 12 weeks than those without (9.1% vs 6.3%, p = 0.04). Mediation analysis revealed that mortality was significantly higher (OR = 1.43, Sobel test p = 0.048) in people with diabetes and ADRs causing AKI. Conclusions: Older multimorbid people with diabetes presenting to hospital with acute illness have significantly more ADRs than those without, and a significantly higher mortality that is mediated by medication-associated AKI and poorer renal function.Peer reviewe

Incident adverse drug reactions in geriatric inpatients : a multicentred observational study

Background: Adverse drug reactions (ADRs) are common in older adults and frequently have serious clinical and economic consequences. This study was conducted as a feasibility study for a randomized control trial (RCT) that will investigate the efficacy of a software engine to optimize medications and reduce incident (in-hospital) ADRs. This study's objectives were to (i) establish current incident ADR rates across the six sites participating in the forthcoming RCT and (ii) assess whether incident ADRs are predictable. Methods: This was a multicentre, prospective observational study involving six European hospitals. Adults aged 65 years, hospitalized with an acute illness and on pharmacological treatment for three or more conditions were eligible for inclusion. Adverse events (AEs) were captured using a trigger list of 12 common ADRs. An AE was deemed an ADR when its association with an administered drug was adjudicated as being probable/certain, according to the World Health Organization Uppsala Monitoring Centre causality assessment. The proportion of patients experiencing at least one, probable/certain, incident ADR within 14 days of enrolment/discharge was recorded. Results: A total of 644 patients were recruited, evenly split by sex and overwhelmingly of White ethnicity. Over 80% of admissions were medical. The median number of chronic conditions was five (interquartile range 4-6), with eight or more conditions present in approximately 10%. The mean number of prescribed medications was 9.9 (standard deviation 3.8), which correlated strongly with the number of conditions (r = 0.54, p < 0.0001). A total of 732 AEs were recorded in 382 patients, of which 363 were incident. The majority of events were classified as probably or possibly drug related, with heterogeneity across sites (chi(2) = 88.567, df = 20, p value < 0.001). Out of 644 patients, 139 (21.6%; 95% confidence interval 18.5-25.0%) experienced an ADR. Serum electrolyte abnormalities were the most common ADR. The ADRROP (ADR Risk in Older People) and GerontoNet ADR risk scales correctly predicted ADR occurrence in 61% and 60% of patients, respectively. Conclusion: This feasibility study established the rates of incident ADRs across the six study sites. The ADR predictive power of ADRROP and GerontoNet ADR risk scales were limited in this population

Efficacy of non-pharmacological interventions to treat malnutrition in older persons : A systematic review and meta-analysis. The SENATOR project ONTOP series and MaNuEL Knowledge Hub project

The preparation of this paper was supported by the MalNutrition in the ELderly (MaNuEL) knowledge hub. MaNuEL is supported by the Joint Programming Initiative ‘Healthy Diet for a Healthy Life’. The MaNuEL funding agencies supporting this paper are (in alphabetical order of participating Member State): France: Ecole Supérieure d’Agricultires (ESA); Germany: Federal Ministry of Food and Agriculture (BMEL) represented by Federal Office for Agriculture and Food (BLE); The Netherlands: The Netherlands Organisation for Health Research and Development (ZonMw). This work was also supported by the SENATOR trial (FP7-HEALTH-2012-305930).Peer reviewedPostprin

Deprescribing tool for STOPPFall (screening tool of older persons prescriptions in older adults with high fall risk) items

Background: Health care professionals are often reluctant to deprescribe fall-risk-increasing drugs (FRIDs). Lack of knowledge and skills form a significant barrier. To support clinicians in the management of FRIDs and to facilitate the deprescribing process, a deprescribing tool was developed by a European expert group for STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) items. Methods: STOPPFall was created using an expert Delphi consensus process in 2019 and in 2020, 24 panellists from EuGMS SIG on Pharmacology and Task and Finish on FRIDs completed deprescribing tool questionnaire. To develop the questionnaire, a Medline literature search was performed. The panellists were asked to indicate for every medication class a possible need for stepwise withdrawal and strategy for withdrawal. They were asked in which situations withdrawal should be performed. Furthermore, panellists were requested to indicate those symptoms patients should be monitored for after deprescribing and a possible need for follow-ups. Results: Practical deprescribing guidance was developed for STOPPFall medication classes. For each medication class, a decision tree algorithm was developed including steps from medication review to symptom monitoring after medication withdrawal. Conclusion: STOPPFall was combined with a practical deprescribing tool designed to optimize medication review. This practical guide can help overcome current reluctance towards deprescribing in clinical practice by providing an up-to-date and straightforward source of expert knowledge

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

Optimizing pharmacotherapy in older patients : an interdisciplinary approach

Aging seems to be a longer lasting pandemic than COVID. Older people enjoy living happily despite a rapidly increasing disease burden, and this has to do with the robust and expanding achievements of hygiene and medicine. This may or may not include the most important option for treatment in almost all therapeutic areas, which is the prescription of drugs. Medication can positively contribute to disease prevention and mitigation, but due to inevitable side effects it could also be limiting the enjoyment of life or even end it. This topic of medication in older people thus is of paramount importance for this steadily growing population part of our industrial societies. The new book on Optimizing pharmacotherapy in older patients is one of the very few attempts to condense our knowledge on this issue and comprehensively detail the dimensions, implications, and technical accommodations for coping with this challenging aspect of medicine. In its 29 chapters, the book deals with the epidemiology of “polypharmacy” (a widely used, but incorrect term which should rather be multimedication), the detrimental impact of some pharmacodynamic and pharmacokinetic features of the aging body on therapeutic outcomes and on instruments, practices, and tools to optimize medication use in older people. Catchwords like “deprescribing” or “potentially inappropriate medications” (PIM) are defned and discussed in the current scientifc context. Drug–drug, drug–nutrient, and drug–disease interactions are being exemplifed, issues of adherence and the roles of potential networking partners such as pharmacists addressed in chapters by outstanding researchers in the area. The content of this frst section on general issues is applied to geriatric syndromes such as frailty or falls, and to special aspects of medications for frequent diseases in older people (e.g., hypertension or heart failure) in the second main part of the book. It thus does not only provide the theoretical background but also practical, disease-oriented solutions to medication-related problems in older people. In its comprehensive approach, this book provides all relevant information for enabling a better and more appropriate medication process in the geriatric population. The book, thus, addresses physicians both in ambulatory and clinical care, pharmacists, nursing staff, and all care providers involved in the complex process of individualized medication in older people. Only few similar books have been published on this important issue to date, but none is comparably actual and comprehensive. We are convinced that this new book is instructive, helpful, and protective in this context by not only showing the risks, but also the opportunities by the correct application of drugs in older people. It clearly conveys that drugs may harm, but also successfully treat older people if chosen correctly. The current FORTA-list contains 41% of positively labelled drugs. Thus, the right drug for the right patient is still a very good option for older people to live longer and/or better

The adverse drug reaction risk in older persons (ADRROP) prediction scale : derivation and prospective validation of an ADR risk assessment tool in older multi-morbid patients

Background: Adverse drug reactions (ADRs) cause serious morbidity and mortality in multi-morbid older adults. Reliable ADR risk prediction would improve patient safety in this at-risk population. We aimed to derive and validate a new predictive tool for assessing ADR Risk in Older People (acronym ADRROP). Design: We combined four databases describing 2217 older people hospitalized with acute illness in order to determine risk factor variables significantly associated with ADRs. We identified the independent ADR risk factors from 1687 patients (derivation cohort) and used them to construct the ADRROP scale. We prospectively validated ADRROP using data from 530 patients (validation cohort). We applied area under the curve (AUC) analysis to test ADRROP's ADR predictive power. We also compared ADRROP's performance to the GerontoNet ADR risk scale. Results: Eight independent ADR risk factors were identified in the derivation patient cohort: female gender, age >70 years, estimated GFR = 1 daily activity, >= 4 co-morbidities, liver disease, presence and number of STOPP criteria-defined potentially inappropriate medications, and >= 1 fall in the previous year. The ADRROP predictive scale constructed from these combined variables ranged from 0 to 27. The derivation cohort AUC value was 0.623 (95% CI 0.598-0.665); the validation cohort AUC was 0.592 (95% CI 0.532-0.652). Applying the GerontoNet ADR risk scale to the combined cohorts yielded an AUC of 0.566 (95% CI 0.537-0.596). Conclusions and relevance: Neither ADRROP nor the GerontoNet ADR risk scale predicted ADRs to a high level in hospitalized older people with multi-morbidity