Development in Prescriptions of Contraindicated and Potentially Harmful QT Interval-Prolonging Drugs in a Large Geriatric Inpatient Cohort From 2011 to 2021.

Regulatory authorities put major emphasis on QT (interval)-prolonging properties of new molecular entities. Product information/Summaries of Product Characteristics (SmPCs) of multiple drugs contain warnings or contraindications regarding QT prolongation, e.g., on coadministration of QT-prolonging drugs (QT drugs). To characterize the development of the QT drug burden, we performed a trend analysis of prescriptions and co-prescriptions of QT drugs in a large geriatric inpatient cohort. The German SmPCs (status of 2014 and of 2021) and the year-wise listings in the CredibleMeds® database from 2011 to 2021 were used as sources. There were 402,631 geriatric cases included. The group of QT drugs according to SmPCs in 2014, which must not be combined with other QT drugs, was less frequently involved in contraindicated co-prescriptions in 2021 compared with 2015 (3.0% (2.5-3.7%) of cases with at least one of those drugs in 2021 vs. 4.0% (3.5-4.5%) in 2015), with citalopram, escitalopram, and amiodarone involved in nearly 90% of the co-prescriptions. The number of CredibleMeds-QT-drugs per patient increased from 0.4 (SD=1.1) in 2011 to 1.8 (SD=3.9) in 2021. The percentage of contraindicated co-prescriptions of drugs with known risk for torsade de pointes according to CredibleMeds® listings at the beginning of the respective years increased from 1.7% in 2011 to 6.1% in 2021. Considering the regularly updated CredibleMeds® QT drugs list, the contraindicated co-prescriptions of QT drugs markedly increased in the last decade. If prescribers considered only the few most frequently (co-) prescribed QT drugs, then most of the medication errors regarding QT drugs could be prevented.

Is the conservative treatment of sacral insufficiency fractures still up to date? Retrospective clinical observational study in 46 patients.

BACKGROUND: According to current forecasts, our society will grow older and older, so that the proportion of 6% of the German population from 2017 who were 80 years or older will increase further. The frequency of falls in this patient population lead to a further increase of sacral insufficiency fractures. HYPOTHESIS: The aim of this study is to evaluate the multimodal interdisciplinary conservative therapy regime for sacral insufficiency fractures in geriatric patients, especially on the basis of mobility and the need for assistance. PATIENTS AND METHODS: A cohort of patients, who were treated as inpatients at the Waldkrankenhaus St. Marien in Erlangen with ICD-10 for sacral fractures S32.1 as the main diagnosis, was retrospectively examined. Only newly diagnosed sacral insufficiency fractures were taken into account. Patients were divided into groups based on the factors hospital stay, fracture location on the sacrum, and location of concomitant pelvic ring injury. The Barthel Index, the Tinetti's Mobility Test and the Timed Up&Go Test were recorded. RESULTS: 46 patients met the inclusion criteria. Using the conservative therapy, improvements were achieved in all patients in terms of need for care, mobility without aids and risk of falling, also patients with an anterior and posterior pelvic ring fracture. Regard a score improvement in the Barthel Index and Tinetti Mobility Test, patients with bilateral sacral insufficiency fracture (n=17, 37.0%) did not differ significantly from patients with unilateral sacral insufficiency fracture (n=22, 47.8%). CONCLUSION: In geriatric patients, decisions about therapy should always be made on an individual and interdisciplinary basis. The conservative therapy regimen continues to play an important role in this. The collected tests-consisting of Barthel Index, Tinetti Mobility Test and Timed Up&Go Test-are well suited for further reproducible, objective studies with a larger patient collective. LEVEL OF EVIDENCE: IV.

Prevalence and treatment of atrial fibrillation in older adults.

BACKGROUND: Atrial fibrillation (AF) is the most frequent cardiac arrhythmia with an impact on morbidity and mortality found in the geriatric population. OBJECTIVE: This retrospective study is the first to investigate the prevalence, treatment and comorbidities of AF in a large cohort of older adults. MATERIAL AND METHODS: Older adults with AF hospitalized between 2010 and 2018. The mean age of the 10,700 AF patients in 2018 was 83.2 ± 6.4 years. The frequency of anticoagulation in older adults with AF between 2010 and 2018 was analyzed. The relationship between comorbidities and anticoagulation in 2018 was examined. Logistic regression analysis was used to identify possible predictive factors for anticoagulation. RESULTS: The prevalence of AF in 35,887 hospitalized older adults was 29.8% in 2018. The mean CHA2DS2VASc score was 4.4 ± 1.3 (male 3.8 ± 1.3, female 4.7 ± 1.2). From 2010 to 2018, the frequency of anticoagulation for patients with AF rose from 32.1% to 64.2%. Statistically significant differences in the examined characteristics between anticoagulated and not anticoagulated patients were found. Furthermore, there were no predictive factors for anticoagulation in multivariate logistic analysis. CONCLUSION: Hospitalized older adults have an increased prevalence of AF compared to the general population. Despite the higher risk of bleeding, older adults were more frequently anticoagulated in the observation period, preferably with direct oral anticoagulants (DOACs). Patients without anticoagulation had more diagnoses and were worse in functional tests. This study suggests that the decision to give anticoagulants to older adults should be personalized.

Use of medication data alone to identify diagnoses and related contraindications: Application of algorithms to close a common documentation gap.

AIMS: Automated checks for medication-related problems have become a cornerstone of medication safety. In many clinical settings medication checks remain confined to drug-drug interactions because only medication data are available in an adequately coded form, leaving possible contraindicated drug-disease combinations unaccounted for. Therefore, we devised algorithms that identify frequently contraindicated diagnoses based on medication patterns related to these diagnoses. METHODS: We identified drugs that are associated with diseases constituting common contraindications based on their exclusive use for these conditions (such as allopurinol for gout or salbutamol for bronchial obstruction). Expert-based and machine learning algorithms were developed to identify diagnoses based on highly specific medication patterns. The applicability, sensitivity and specificity of the approach were assessed by using an anonymized real-life sample of medication and diagnosis data excerpts from 3506 discharge records of geriatric patients. RESULTS: Depending on the algorithm, the desired focus (i.e., sensitivity vs. specificity) and the disease, we were able to identify the diagnoses gout, epilepsy, coronary artery disease, congestive heart failure and bronchial obstruction with a specificity of 44.0-99.8% (95% CI 41.7-100.0%) and a sensitivity of 3.8-83.1% (95% CI 1.0-86.1%). Using only medication data, we were able to identify 123 (51.3%) of 240 contraindications identified by experts with access to medication data and diagnoses. CONCLUSION: This study provides a proof of principle that some key diagnosis-related contraindications can be identified based on a patient's medication data alone, while others cannot be identified. This approach offers new opportunities to analyse drug-disease contraindications in community pharmacy or clinical routine data.

Frail Older Individuals Maintaining a Steady Standing Position: Associations Between Sway Measurements with Frailty Status Across Four Different Frailty Instruments.

OBJECTIVE: An analysis of the relationships between static equilibrium parameters and frailty status and/or severity across four different frailty measures. DESIGN: Cross-sectional analysis. SETTING: Geriatric wards of a general hospital. PARTICIPANTS: One hundred twenty-three geriatric inpatients comprising 70 women (56.5%) and 53 men (42.7%) with an age range of 68-95 years. METHODS: The variation in the center of pressure (CoP), ie, the length of sway, the area of sway, and the mean speed, was assessed for different positions/tasks: 1) wide standing with eyes open (WSEO); 2) wide standing with eyes closed (WSEC); 3) narrow standing with eyes open (NSEO) and 4) narrow standing with eyes closed (NSEC), using a force plate. Frailty status and/or frailty severity were evaluated using the frailty phenotype (FP), the clinical frailty scale (CFS), the 14-item frailty index based on a comprehensive geriatric assessment (FI-CGA), and a 47-item frailty index (FI). RESULTS: WSEO length of sway (FP, CFS, FI-CGA, FI), WSEO area of sway (FP, CFS, FI-CGA, FI), and WSEO mean speed (FP, CFS, FI-CGA, FI), WSEC length of sway (FP, FI-CGA, FI), WSEC area of sway (FP, FI-CGA, FI) and WSEC mean speed (FI-CGA, FI), NSEO length of sway (FP, FI-CGA, FI), NSEO area of sway (FP, CFS, FI-CGA, FI), and NSEO mean speed (FP, CFS, FI-CGA, FI), NSEC length of sway (FI-CGA, FI), NSEC area of sway (FI-CGA, FI) and NSEC mean speed (FI-CGA, FI) were associated with the frailty status and/or severity across the four different frailty instruments (all p < 0.05, respectively). CONCLUSION: Greater fluctuations in CoP with increasing frailty status and/or severity were a uniform finding across various major frailty instruments.

Predictability of a modified Mini- Nutritional- Assessment version on six-month and one-year mortality in hospitalized geriatric patients: a comparative analysis.

Recently we introduced a modified Mini Nutritional Assessment (MNA) Short Form (MNA-SF) and Long Form (MNA-SF) with operationalization of the 'mobility' and 'neuropsychological problems' items of the MNA using scores on Barthel Index mobility item and Mini Mental State Examination and Geriatric Depression Scale scores. We have now evaluated the abilities of this modified MNA-SF and MNA-LF to predict mortality in comparison with the standard MNA-SF and MNA-LF and the Nutritional Risk Screening 2002 (NRS 2002) and the Malnutrition Universal Screening Tool (MUST). A prospective analysis was performed in 240 hospitalised geriatric patients aged ≥ 65 years. Malnutrition and/or malnutrition risk were assessed using the modified MNA-SF and MNA-LF, the standard MNA-SF and MNA-LF, and the NRS 2002 and MUST. The modified MNA-SF and MNA-LF and the standard MNA-SF and MNA-LF assessments (all p < 0.05), but not NRS 2002 or MUST (all p ≥ 0.05), predicted six-month and/or one-year mortality. Prediction of six-month and/or one-year mortality by the modified MNA-SF was comparable with predictions by the standard MNA-SF and MNA-LF (all p ≥ 0.05). The modified MNA-LF showed better prediction of six-month and one-year mortality than the standard MNA-SF and MNA-LF (all p < 0.05). The modified MNA-LF (all adjusted p < 0.05), but none of the other instruments (all adjusted p ≥ 0.05), predicted six-month and one-year mortality independently of age, sex, frailty, comorbidity and ADL disability burden. The modified MNA-SF and MNA-LF emerged as potentially valuable tools for predicting mortality in patients hospitalised on geriatric wards.

Changes of a frailty index based on common blood and urine tests during a hospital stay on geriatric wards predict 6-month and 1-year mortality in older people.

BACKGROUND: We aimed to evaluate the abilities of a 21-item frailty index based on laboratory blood and urine tests (FI-Lab21) assessed at different points in time, ie, at admission to hospital (FI-Lab21admission) and before discharge from hospital (FI-Lab21discharge), and the change of the FI-Lab21 during the hospital stay to predict 6-month and 1-year mortality in hospitalized geriatric patients. METHODS: Five hundred hospitalized geriatric patients aged ≥65 years were included in this analysis. Follow-up data were acquired after a period of 6 months and 1 year. RESULTS: The FI-Lab21admission and FI-Lab21discharge scores were 0.33±0.15 and 0.31±0.14, respectively (P<0.001). The FI-Lab21admission and FI-Lab21discharge both predicted 6-month and 1-year mortality (areas under the receiver operating characteristic curves: 0.72, 0.72, 0.77, and 0.75, respectively, all P<0.001). The predictive abilities for 6-month and 1-year mortality of the FI-Lab21admission were inferior compared with those of the FI-Lab21discharge (all P<0.05). Patients with a reduction in or stable FI-Lab21 score during the hospital stay revealed lower 6-month and 1-year mortality rates compared with the persons whose FI-Lab21 score increased during the hospital stay (all P<0.05). After adjustment for age, sex, and FI-Lab21admission, each 1% decrease in the FI-Lab21 during the hospital stay was associated with a decrease in 6-month and 1-year mortality of 5.9% and 5.3% (both P<0.001), respectively. CONCLUSION: The FI-Lab21 assessed at admission or discharge and the changes of the FI-Lab21 during the hospital stay emerged as interesting and feasible approaches to stratify mortality risk in hospitalized geriatric patients.

Operationalizing a frailty index using routine blood and urine tests.

BACKGROUND: Uncomplicated frailty instruments are desirable for use in a busy clinical setting. The aim of this study was to operationalize a frailty index (FI) from routine blood and urine tests, and to evaluate the properties of this FI compared to other frailty instruments. MATERIALS AND METHODS: We conducted a secondary analysis of a prospective cohort study on 306 patients aged ≥65 years hospitalized on geriatric wards. An FI comprising 22 routine blood parameters and one standard urine parameter (FI-Lab), a 50-item FI based on a comprehensive geriatric assessment (FI-CGA), a combined FI (FI-combined [items from the FI-Lab + others from the FI-CGA]), the Clinical Frailty Scale, rule-based frailty definition, and frailty phenotype were operationalized from data obtained during patients' hospital stays (ie, before discharge [baseline examination]). Follow-up data were obtained up to 1 year after the baseline examination. RESULTS: The mean FI-Lab score was 0.34±15, with an upper limit of 0.74. The FI-Lab was correlated with all the other frailty instruments (all P<0.001). The FI-Lab revealed an area under the receiver-operating characteristic curve (AUC) for 6-month and 1-year mortality of 0.765 (0.694-0.836) and 0.769 (0.706-0.833), respectively (all P<0.001). Each 0.01 increment in FI-Lab increased the risk (adjusted for age and sex) for 6-month and 1-year mortality by 7.2% and 7.1%, respectively (all adjusted P<0.001). When any of the other FIs (except the FI-combined) were also included in the models, each 0.01 increment in FI-Lab score was associated with an increase in the risk of 6-month and 1-year mortality by 4.1%-5.4% (all adjusted P<0.001). CONCLUSION: The FI-Lab showed key characteristics of an FI. The FI-Lab can be applied as a single frailty measure or in combination with/in addition to other frailty instruments.

Instrumented gait analysis: a measure of gait improvement by a wheeled walker in hospitalized geriatric patients.

BACKGROUND: In an increasing aging society, reduced mobility is one of the most important factors limiting activities of daily living and overall quality of life. The ability to walk independently contributes to the mobility, but is increasingly restricted by numerous diseases that impair gait and balance. The aim of this cross-sectional observation study was to examine whether spatio-temporal gait parameters derived from mobile instrumented gait analysis can be used to measure the gait stabilizing effects of a wheeled walker (WW) and whether these gait parameters may serve as surrogate marker in hospitalized patients with multifactorial gait and balance impairment. METHODS: One hundred six patients (ages 68-95) wearing inertial sensor equipped shoes passed an instrumented walkway with and without gait support from a WW. The walkway assessed the risk of falling associated gait parameters velocity, swing time, stride length, stride time- and double support time variability. Inertial sensor-equipped shoes measured heel strike and toe off angles, and foot clearance. RESULTS: The use of a WW improved the risk of spatio-temporal parameters velocity, swing time, stride length and the sagittal plane associated parameters heel strike and toe off angles in all patients. First-time users (FTUs) showed similar gait parameter improvement patterns as frequent WW users (FUs). However, FUs with higher levels of gait impairment improved more in velocity, stride length and toe off angle compared to the FTUs. CONCLUSION: The impact of a WW can be quantified objectively by instrumented gait assessment. Thus, objective gait parameters may serve as surrogate markers for the use of walking aids in patients with gait and balance impairments.

Comparing the predictive accuracy of frailty, comorbidity, and disability for mortality: a 1-year follow-up in patients hospitalized in geriatric wards.

BACKGROUND: Studies evaluating and comparing the power of frailty, comorbidity, and disability instruments, together and in parallel, for predicting mortality are limited. OBJECTIVE: This study aimed to evaluate and compare the measures of frailty, comorbidity, and disability in predicting 1-year mortality in geriatric inpatients. DESIGN: Prospective cohort study. PATIENTS AND SETTING: A total of 307 inpatients aged ≥65 years in geriatric wards of a general hospital participated in the study. MEASUREMENTS: The patients were evaluated in relation to different frailty, comorbidity, and disability instruments during their hospital stays. These included three frailty (the seven-category Clinical Frailty Scale [CFS-7], a 41-item frailty index [FI], and the FRAIL scale), two comorbidity (the Cumulative Illness Rating Scale for Geriatrics [CIRS-G] and the comorbidity domain of the FI [Comorbidity-D-FI]), and two disability instruments (disability in basic activities of daily living [ADL-Katz] and the instrumental and basic activities of daily living domains of the FI [IADL/ADL-D-FI]). The patients were followed-up over 1 year. RESULTS: Using FI, CIRS-G, Comorbidity-D-FI, and ADL-Katz, this study identified a patient group with a high (≥50%) 1-year mortality rate in all of the patients and the two patient subgroups (ie, patients aged 65-82 years and ≥83 years). The CFS-7, FI, FRAIL scale, CIRS-G, Comorbidity-D-FI, and IADL/ADL-D-FI (analyzed as full scales) revealed useful discriminative accuracy for 1-year mortality (ie, an area under the curve >0.7) in all the patients and the two patient subgroups (all P<0.001). Thereby, CFS-7 (in all patients and the two patient subgroups) and FI (in the subgroup of patients aged ≥83 years) showed greater discriminative accuracy for 1-year mortality compared to other instruments (all P<0.05). CONCLUSION: All the different instruments emerged as suitable tools for risk stratification in geriatric inpatients. Among them, CFS-7, and in those patients aged ≥83 years, also the FI, might most accurately predict 1-year mortality in the aforementioned group of individuals.

Anticholinergic burden and cognitive function in a large German cohort of hospitalized geriatric patients.

PURPOSE: Previous studies suggest an association between use of anticholinergic drugs in elderly patients and cognitive impairment. However, there are still limited data on the association of anticholinergic drug use and cognitive impairment as well as contribution of individual drugs to anticholinergic load using large, well-documented patient cohorts treated in geriatric units from Europe. METHODS: We investigated 797,440 prescriptions to 89,579 hospitalized patients treated in geriatric units within the GiB-DAT database. Data of all patients discharged between 1 January 2013 and 30 June 2015 was included. The Anticholinergic Cognitive Burden (ACB) scale was used to classify anticholinergic drugs as definite (score 2 or 3) and possible anticholinergics (score 1). Cognitive function was determined using Mini-Mental State Examination (MMSE) and the standardized scale for dementia (4D+S). RESULTS: In two multivariable logistic regression models age, sex, number of drugs and ACB total scores were identified as variables independently associated with cognitive impairment as measured by MMSE (odds ratio per ACB unit 1.114, 95% CI 1.099-1.130) or the diagnosis dementia (odds ratio 1.159 per ACB unit, 95% CI 1.144-1.173, both p < 0.0001). High anticholinergic load was associated with patients with severe cognitive impairment (p < 0.05 for all pairwise comparisons). ACB score 3 anticholinergic drugs contributed 77.9% to the cumulative amount of ACB points in patients with an anticholinergic load of 3 and higher. CONCLUSIONS: Using a cross-sectional study design, a significant positive association between anticholinergic drug load and cognitive impairment in European patients treated in specialised geriatric units was found. The most frequently used definitve anticholinergic drugs were quetiapine, amitriptyline and carbamazepine.

Significance of frailty for predicting adverse clinical outcomes in different patient groups with specific medical conditions.

Frailty is a major health burden in an aging society. It constitutes a clinical state of reduced physiological reserves that is associated with a diminished ability to withstand internal and external stressors. Frail patients have an increased risk for adverse clinical outcomes, such as mortality, readmission to hospital, institutionalization and falls. Of further clinical interest, frailty might be at least in part reversible in some patients and subject to preventive strategies. In daily clinical practice older patients with a complex health status, who are mostly frail or at least at risk of developing frailty, are frequently cared for by geriatricians. Recently, clinicians and scientists from other medical disciplines, such as cardiology, pulmonology, gastroenterology, nephrology, endocrinology, rheumatology, surgery and critical care medicine also discovered frailty to be an interesting instrument for risk stratification of patients, including younger patients. In this review we highlight the results of recent studies that demonstrated the significance of frailty to predict adverse clinical outcomes in patients with specific medical conditions, such as cardiac, lung, liver and kidney diseases as well as diabetes mellitus, osteoarthritis, trauma patients, patients undergoing surgery and critically ill patients. Multiple studies in patients with the aforementioned specific medical conditions could be identified demonstrating a predictive role of frailty for several adverse clinical outcomes. The association between frailty and adverse clinical outcomes reported in these studies was in part independent of several major potential confounder factors, such as age, sex, race, comorbidities and disabilities and were also detected in younger patients.

Co-Prescription of QT-Interval Prolonging Drugs: An Analysis in a Large Cohort of Geriatric Patients.

BACKGROUND: Drug-induced QT-interval prolongation is associated with occurrence of potentially fatal Torsades de Pointes arrhythmias (TdP). So far, data regarding the overall burden of QT-interval prolonging drugs (QT-drugs) in geriatric patients are limited. OBJECTIVE: This study was performed to assess the individual burden of QT-interval prolonging drugs (QT-drugs) in geriatric polymedicated patients and to identify the most frequent and risky combinations of QT-drugs. METHODS: In the discharge medication of geriatric patients between July 2009 and June 2013 from the Geriatrics in Bavaria-Database (GiB-DAT) (co)-prescriptions of QT-drugs were investigated. QT-drugs were classified according to a publicly available reference site (CredibleMeds®) as ALL-QT-drugs (associated with any QT-risk) or High-risk-QT-drugs (corresponding to QT-drugs with known risk of Torsades de Pointes according to CredibleMeds®) and in addition as SmPC-high-risk-QT-drugs (according to the German prescribing information (SmPC) contraindicated co-prescription with other QT-drugs). RESULTS: Of a cohort of 130,434 geriatric patients (mean age 81 years, 67% women), prescribed a median of 8 drugs, 76,594 patients (58.7%) received at least one ALL-QT-drug. Co-prescriptions of two or more ALL-QT-drugs were observed in 28,768 (22.1%) patients. Particularly risky co-prescriptions of High-risk-QT-drugs or SmPC-high-risk-QT-drugs with at least on further QT-drug occurred in 55.9% (N = 12,633) and 54.2% (N = 12,429) of these patients, respectively. Consideration of SmPCs (SmPC-high-risk-QT-drugs) allowed the identification of an additional 15% (N = 3,999) patients taking a risky combination that was not covered by the commonly used CredibleMeds® classification. Only 20 drug-drug combinations accounted for more than 90% of these potentially most dangerous co-prescriptions. CONCLUSION: In a geriatric study population co-prescriptions of two and more QT-drugs were common. A considerable proportion of QT-drugs with higher risk only could be detected by using more than one classification-system. Local adaption of international classifications can improve identification of patients at risk.

Inertial sensor-based stride parameter calculation from gait sequences in geriatric patients.

A detailed and quantitative gait analysis can provide evidence of various gait impairments in elderly people. To provide an objective decision-making basis for gait analysis, simple applicable tests analyzing a high number of strides are required. A mobile gait analysis system, which is mounted on shoes, can fulfill these requirements. This paper presents a method for computing clinically relevant temporal and spatial gait parameters. Therefore, an accelerometer and a gyroscope were positioned laterally below each ankle joint. Temporal gait events were detected by searching for characteristic features in the signals. To calculate stride length, the gravity compensated accelerometer signal was double integrated, and sensor drift was modeled using a piece-wise defined linear function. The presented method was validated using GAITRite-based gait parameters from 101 patients (average age 82.1 years). Subjects performed a normal walking test with and without a wheeled walker. The parameters stride length and stride time showed a correlation of 0.93 and 0.95 between both systems. The absolute error of stride length was 6.26 cm on normal walking test. The developed system as well as the GAITRite showed an increased stride length, when using a four-wheeled walker as walking aid. However, the walking aid interfered with the automated analysis of the GAITRite system, but not with the inertial sensor-based approach. In summary, an algorithm for the calculation of clinically relevant gait parameters derived from inertial sensors is applicable in the diagnostic workup and also during long-term monitoring approaches in the elderly population.

Implementation of warnings from Dear Doctor Letters (Rote-Hand-Briefe): an analysis of medication data from a large cohort of elderly patients.

BACKGROUND: Dear Doctor Letters (also known as Direct Healthcare Professional Communications) inform physicians about significant newly discovered drug risks and about measures to take to reduce these risks. How far these warnings actually influence prescribing behavior is unclear. METHOD: The Geriatrics in Bavaria-Database (GiB-DAT, Geriatrie in Bayern Datenbank) collects data from more than 50 centers offering inpatient geriatric health care. Based on GiB-DAT data, the discharge medication of 76 568 patients (81 ± 8 years, 67% women) was recorded in a standardized manner and analyzed for the implementation of information contained in two Dear Doctor Letters about the risks of dose-related or drug interaction-related QT interval prolongation caused by citalopram or escitalopram. RESULTS: Patients were discharged with a median of 8 drugs. In the four quarters of 2012 following release of the Dear Doctor Letters, in comparison to the four quarters before their publication, a marked drop from 9.8% to 4.1% was seen in prescriptions for >20 mg/day citalopram--a dosage no longer recommended in elderly patients--and a similar drop from 23.6% to 12.8% in prescriptions for >10 mg/day escitalopram (p<0.0001). Co-prescription of either of these two drugs with other QT interval-prolonging drugs, which was now contraindicated, remained almost unchanged (citalopram: 19.3% [95% confidence interval (CI): 17.9-20.9%] versus 18.4% [95% CI: 17.0-19.8%]; escitalopram: 17.6% [95% CI: 15.8-19.6%] versus 17.1% [95% CI: 14.5-19.9%]). CONCLUSION: Simple information in Dear Doctor Letters, such as a reduction of the maximum daily dose, was better implemented than complicated information regarding contraindicated co-medication. Quality assurance systems such as the GiB-DAT network make it possible to identify problems of this kind. Licensing authorities and pharmaceutical companies should should improve the clinical usability, e.g., by providing official reference lists of drugs with safety warnings.

Potentially inappropriate medications in a large cohort of patients in geriatric units: association with clinical and functional characteristics.

OBJECTIVE: With the aim of reducing the risk of adverse drug effects, expert groups have defined lists of potentially inappropriate medications (PIM) for drug therapy in the elderly. However, it is unclear whether use of PIM at discharge from specialized geriatric units is associated with altered clinical characteristics. METHODS: A post-hoc analysis of 376,335 drug prescriptions in 45,809 patients aged 70 years or older at discharge from 44 geriatric units located in Bavaria was performed (1 January 2009 to 31 December 2010). The main outcome measures were patient-related characteristics including functional status, which were independently associated in a multivariable logistic regression model with PIM at discharge. RESULTS: Male gender was associated with a lower odds ratio (OR) for the use of PIM [OR 0.72, 95 % confidence interval (CI) 0.67-0.76, P < 0.001]. The Barthel score at discharge was associated with a modestly increased odds ratio for receiving at least one PIM (OR 1.00, 95 % CI 1.00-1.01, P < 0.001). Patients who were only able to walk with assistant or who were unable to walk in the Timed Up-and-Go-Test, had adjusted odds ratios of 1.18 (95 % CI 1.08-1.28, P < 0.001) and 1.22 (95 % CI 1.07-1.39, P = 0.003), respectively, for receiving PIM. In additional multivariate analyses we found no evidence for a significant impact of PIM use on the change in the Barthel score during the hospital stay and on the ability to walk. CONCLUSIONS: Several factors, including gender and Barthel score, are associated with the use of drugs classified as potentially inappropriate for drug therapy in the elderly. However, the use of potentially inappropriate medications is not a clinically meaningful indicator of functional status at discharge.

Reliability analysis of time series force plate data of community dwelling older adults.

Frequency-based analysis of body sway has been used to distinguish between healthy young, healthy elderly adults and elderly adults with Huntingtons disease. Our aim was to assess the reliability of spectral-based outcomes of the centre of pressure (CoP) kinematics in order to determine if these outcomes could be tested for their capability to distinguish between elderly fallers and non-fallers in a future study. We have studied balance for 30 community dwelling healthy older adults 60 years or older. Four test conditions were used. Three successive trials were performed for each condition. CoP kinematics were estimated with a force platform with three strain gauges set in a triangular position. The frequency content of these signals was estimated. Intrasession correlation coefficients (ICC's) were then calculated for all test conditions. The reliability of the selected parameters varied between low and high (ICC 0.652-0.939). The ICC's for the narrow stance tests were higher compared to tests with normal standing conditions (0.771-0.94) to (0.652-0.865). The highest value was obtained in the high frequency band (0.939). These measures should be viewed with caution when screening geriatric patients because their reliability cannot always be assumed.

Intrasession reliability of force platform parameters in community-dwelling older adults.

OBJECTIVE: To investigate the intrasession reliability of center of pressure (COP) parameters calculated from force platform measurements. DESIGN: A cross-sectional study. SETTING: Gait and balance laboratory. PARTICIPANTS: Community-dwelling healthy older adults (N=63) above the age of 62 years (mean age, 78.74 y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: COP was estimated from a force platform, and the following parameters were calculated: (1) the total length of the COP displacement, (2) area of sway, (3) length of the COP displacement in the sagittal plane, and (4) length of the COP displacement in the frontal plane. Intraclass correlation coefficients (ICCs) were calculated by using 3 successive trials with 4 different test conditions. The test conditions were (1) normative standing with eyes open, (2) normative standing with eyes closed, (3) narrow stance with eyes open, and (4) narrow stance with eyes closed. RESULTS: The ICCs for the tests with eyes closed (.710-.946) were higher than those for tests with eyes open (.841-.945). The highest value was obtained for the vector sum of the COP during anteroposterior movement in narrow stance with eyes closed (.946). The value .710 was the lowest of all parameters and was an outlier for the narrow stance with eyes closed test, which was otherwise very reliable. CONCLUSIONS: Eight of 16 calculated ICCs showed excellent reliability (>.90). They can be recommended for further use in clinical trials. Tests with closed eyes were more reliable than tests with eyes open. We recommend using eyes closed test conditions when assessing static balance control. For these tests, all the calculated ICCs were over .90, except for measurements of sway area.