Adverse drug reactions in older people : detection and prevention

Adverse drug reactions (ADRs) in older adults are an important healthcare problem since they are frequently a cause of hospitalization, occur commonly during admission, and are an important cause of morbidity and mortality. Older adults are particularly susceptible to ADRs because they are usually on multiple drug regimens and because age is associated with changes in pharmacokinetics and pharmacodynamics. The presentation of an ADR in older adults is often atypical, which further complicates its recognition. One potential strategy for improving recognition of ADRs is to identify those patients who are at risk of an ADR. The recently developed GerontoNet ADR Risk Score is a practical tool for identification of older patients who are at increased risk for an ADR and who may represent a target for interventions aimed at reducing ADRs. Provision of adequate education in the domain of clinical geriatric pharmacology can improve recognition of ADRs. Besides formal surveillance systems, built-in computer programs with electronic prescribing databases and clinical pharmacist involvement in patient care within multidisciplinary geriatric teams might help to minimize the occurrence of ADRs. In addition, a number of actions can be taken in hospitals to stimulate appropriate prescribing and to assure adequate communication between primary and hospital care. In older adults with complex medical problems and needs, a global evaluation obtained through a comprehensive geriatric assessment may be helpful in simplifying drug prescription and prioritizing pharmacological and healthcare needs, resulting in an improvement in quality of prescribing

Older patients' prescriptions screening in the community pharmacy: development of the Ghent Older People's Prescriptions community Pharmacy Screening (GheOP3S) tool

Background: Ageing of the population often leads to polypharmacy. Consequently, potentially inappropriate prescribing (PIP) becomes more frequent. Systematic screening for PIP in older patients in primary care could yield a large improvement in health outcomes, possibly an important task for community pharmacists. In this article, we develop an explicit screening tool to detect relevant PIP that can be used in the typical community pharmacy practice, adapted to the European market. Methods: Eleven panellists participated in a two-round RAND/UCLA (Research and Development/University of California, Los Angeles) process, including a round zero meeting, a literature review, a first written evaluation round, a second face-to-face evaluation round and, finally, a selection of those items that are applicable in the contemporary community pharmacy. Results: Eighteen published lists of PIP for older patients were retrieved from the literature, mentioning 398 different items. After the two-round RAND/UCLA process, 99 clinically relevant items were considered suitable to screen for in a community pharmacy practice. A panel of seven community pharmacists selected 83 items, feasible in the contemporary community pharmacy practice, defining the final GheOP3S tool. Conclusion: A novel explicit screening tool (GheOP3S) was developed to be used for PIP screening in the typical community pharmacy practice

Diagnostic approaches and management aspects of early dementia.

This thesis has been written with the aim to identify the problems surrounding the early diagnosis of dementia, especially of the Alzheimer type, and to recommend diagnostic approaches and management aspects, with particular reference to the role which a Memory Clinic can play within this contex

Converting wandering behaviour into a guided activity: a case study of co-designing with People Living with Dementia based on theoretical models

For People Living with Dementia (PLwD), wandering behaviour can cause undesired consequences, such as falling, getting lost or even fatalities. For caregivers, taking care of PLwD with wandering behaviours is burdensome. If not intervened early, some wandering behaviours will escalate into crisis events. This design research aims to explore how to convert the wandering behaviour to a guided activity with the minimum input from caregivers by intervening early, that is, engaging PLwD, to avoid potential escalations. Based on Need-driven Dementia-compromised Behaviour (NDB) model, Crisis Development model and via a co-design approach, we developed De-light. De-light is a set of interactive sticks enhanced by light, audio and tactile experiences. Based on the degree of wandering behaviours of PLwD, De-light can be placed by the caregiver in a safe and suitable area in the nursing home to provide a controlled setting for guiding PLwD to perform physical activity. Our design research implies the possibilities of applying NDB model, Crisis Development model, and co- design approach in designing for the wandering behaviours for PLwD

The influence of drug use on fall incidents among nursing home residents: A systematic review

Background: Falls are a major health problem among the elderly, particularly in nursing homes. Abnormalities of balance and gait, psychoactive drug use, and dementia have been shown to contribute to fall risk. Methods: We conducted a systematic review of the literature to investigate which psychoactive drugs increase fall risk and what is known about the influence of these drugs on gait in nursing home residents with dementia. We included studies with a prospective cohort design on psychoactive drug use in nursing homes with dementia residents and with falls as an outcome measure. Results: Seventeen studies were included in the review. Pooled risk estimates were not calculated because there was no homogeneity across studies. We assessed the strength of evidence for psychoactive drugs as a prognostic factor for falls by defining four levels of evidence: strong, moderate, limited or inconclusive. Strong evidence was defined as consistent findings (≥80%) in at least two high quality cohorts. We found strong evidence that the use of multiple drugs (3/3 cohorts, effect sizes 1.30-1xs0.30), antidepressants (10/12 cohorts, effect sizes 1.10-7.60), and anti-anxiety drugs (2/2 cohorts, effect sizes 1.22-1.32) is associated with increased fall risk. The evidence for the association of other psychoactive drug classes with fall risk was limited or inconclusive. Conclusions: Research on the contribution of psychoactive drugs to fall risk in nursing home residents with dementia is limited. The scarce evidence shows, however, that multiple drugs, antidepressants and anti-anxiety drugs increase fall risk in nursing home populations with residents with dementia

Higher serum vitamin D3 levels are associated with better cognitive test performance in patients with Alzheimer's disease

Background/Aims: Recent studies suggest that vitamin D metabolites may be important for preserving cognitive function via specific neuroprotective effects. No large studies have examined the association between vitamin D status and cognition. Methods: In this cross-sectional study, we analyzed the serum 25-hydroxyvitamin D3levels and Mini-Mental State Examination (MMSE) test scores of 225 older outpatients who were diagnosed as having probable Alzheimer's disease (AD). In addition to the 25-hydroxyvitamin D3levels, we analyzed the serum vitamin B1, B6and B12levels. Results: An association was found between MMSE test scores and serum 25-hydroxyvitamin D3levels, with a β-coefficient of 0.05 (p = 0.01). Vitamin-D-sufficient patients had significantly higher MMSE scores as compared to vitamin-D-insufficient ones. No association was found with the other serum vitamin levels. Conclusions: These data support the idea that a relationship exists between vitamin D status and cognition in patients with probable AD. However, given the cross-sectional design of this study, no causality can be concluded. Further prospective studies are needed to specify the contribution of vitamin D status to the onset and course of cognitive decline and AD. Copyrigh

Introduction

OBJECTIVE: To evaluate developmental and social-emotional outcomes at 8 years of age for children with congenital diaphragmatic hernia (CDH), treated with or without neonatal extracorporeal membrane oxygenation (ECMO) between January 1999 and December 2003. DESIGN: Cohort study with structural prospective follow-up. SETTING: Level III University Hospital. PATIENTS: 35 children (ECMO: n=16; non-ECMO: n=19) were assessed at 8 years of age. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Intelligence and motor function. Concentration, behaviour, school performance, competence and health status were also analysed. RESULTS: Mean (SD) intelligence for the ECMO group was 91.7 (19.5) versus 111.6 (20.9) for the non-ECMO group (p=0.015). Motor problems were apparent in 16% of all participants and differed significantly from the norm (p=0.015) without differences between treatment groups. For all participants, problems with concentration (68%, p<0.001) and with behavioural attention (33%, p=0.021) occurred more frequently than in reference groups, with no difference between treatment groups. School performance and competence were not affected. CONCLUSIONS: Children with CDH-whether or not treated with neonatal ECMO-are at risk for long-term morbidity especially in the areas of motor function and concentration. Despite their impairment, children with CDH have a well-developed feeling of self-competence

Why older people refuse to participate in falls prevention trials: A qualitative study

Background/Objectives: Falls are a major public health problem. Older persons are frequently underrepresented in trials, including falls prevention trials. Insight into possible reasons for non-participation could help to improve trial designs and participation rates among this age-group. The aim of this study was to explore reasons why older people refuse to participate in falls prevention trials. Setting: A qualitative study. Participants: Community-dwelling adults aged ≥ 65. years who attended the Emergency Department due to a fall and refused to participate in a falls prevention trial (IMPROveFALL-study). Measurements: A structured interview guide was used, and interview transcripts were subjected to an independent content analysis by two researchers. Results: 15 interviews were conducted. A main reason to refuse trial participation was mobility impairment. In contrast, younger and more "active" and mobile seniors considered themselves "too healthy" to participate. Persons with multiple comorbidities mentioned that they attended a hospital too often, or experienced adequate follow-up by their own physicians already. Transport problems, including distance to the hospital, parking facilities, and travel expenses were another issue. During the interviews it was emphasized by the patients, that they knew the reason for their fall. However, they were not familiar with the positive effects of falls prevention programmes. Conclusions: Older persons reported multiple reasons to refuse participation in a falls prevention study, such as health-related factors, several practical problems, and personal beliefs about the causes and preventability of falls. Anticipation of those issues might contribute to an improvement in participation rates of older fallers, shorter study duration, and a better generalizability of research findings