Psychotropic medication use and future unexplained and injurious falls and fracture amongst community-dwelling older people: data from TILDA.

PURPOSE: Psychotropic medications (antidepressants, anticholinergics, benzodiazepines, 'Z'-drugs and antipsychotics) are frequently identified as Falls Risk Increasing Drugs. The aim of this study is to clarify the association of psychotropic medication use with future falls/fracture amongst community-dwelling older people. METHODS: Participants ≥ 65 years from TILDA were included and followed from Waves 1 to 5 (8-year follow-up). Incidence of falls (total falls/unexplained/injurious) and fracture was by self-report; unexplained falls were falls not caused by a slip/trip, with no apparent cause. Poisson regression models reporting incidence rate ratios (IRR) assessed the association between medications and future falls/fracture, adjusted for relevant covariates. RESULTS: Of 2809 participants (mean age 73 years), 15% were taking ≥ 1 psychotropic medication. During follow-up, over half of participants fell, with 1/3 reporting injurious falls, over 1/5 reporting unexplained falls and almost 1/5 reporting fracture. Psychotropic medications were independently associated with falls [IRR 1.15 (95% CI 1.00-1.31)] and unexplained falls [IRR 1.46 (95% CI 1.20-1.78)]. Taking ≥ 2 psychotropic medications was further associated with future fracture (IRR 1.47 (95% CI 1.06-2.05)]. Antidepressants were independently associated with falls [IRR 1.20 (1.00-1.42)] and unexplained falls [IRR 2.12 (95% CI 1.69-2.65)]. Anticholinergics were associated with unexplained falls [IRR 1.53 (95% CI 1.14-2.05)]. 'Z'-drug and benzodiazepine use were not associated with falls or fractures. CONCLUSION: Psychotropic medications, particularly antidepressants and anticholinergic medications, are independently associated with falls and fractures. Regular review of ongoing need for these medications should therefore be central to the comprehensive geriatric assessment.

The 'Bermuda Triangle' of orthostatic hypotension, cognitive impairment and reduced mobility: prospective associations with falls and fractures in The Irish Longitudinal Study on Ageing.

BACKGROUND: Orthostatic hypotension (OH), cognitive impairment (Cog) and mobility impairment (MI) frequently co-occur in older adults who fall. This study examines clustering of these three geriatric syndromes and ascertains their relationship with future falls/fractures in a large cohort of community-dwelling people ≥ 65 years during 8-year follow-up. METHODS: OH was defined as an orthostatic drop ≥ 20 mmHg in systolic blood pressure (from seated to standing) and/or reporting orthostatic unsteadiness. CI was defined as Mini Mental State Examination ≤ 24 and/or self-reporting memory as fair/poor. MI was defined as Timed Up and Go ≥12 s. Logistic regression models, including three-way interactions, assessed the longitudinal association with future falls (explained and unexplained) and fractures. RESULTS: Almost 10% (88/2,108) of participants had all three Bermuda syndromes. One-fifth of participants had an unexplained fall during follow-up, whereas 1/10 had a fracture. There was a graded relationship with incident unexplained falls and fracture as the number of Bermuda syndromes accumulated. In fully adjusted models, the cluster of OH, CI and MI was most strongly associated with unexplained falls (odds ratios (OR) 4.33 (2.59-7.24); P < 0.001) and incident fracture (OR 2.51 (1.26-4.98); P = 0.045). Other clusters significantly associated with unexplained falls included OH; CI and MI; MI and OH; CI and OH. No other clusters were associated with fracture. DISCUSSION: The 'Bermuda Triangle' of OH, CI and MI was independently associated with future unexplained falls and fractures amongst community-dwelling older people. This simple risk identification scheme may represent an ideal target for multifaceted falls prevention strategies in community-dwelling older adults.

Hypotensive unawareness in Parkinson's disease-related autonomic dysfunction.

This case demonstrates how orthostatic hypotension in the absence of typical symptoms of light-headedness/dizziness when changing posture, can contribute to the burden of falls in Parkinson's disease. At least one-third of people with severe orthostatic hypotension do not report typical symptoms, and this figure appears to be higher in patients with Parkinson's disease. This is important clinically as it can increase the difficulty in ascribing falls to orthostatic hypotension, especially given the other competing reasons in Parkinson's disease and orthostatic hypotension symptoms can act as a prompt for the patient to act to prevent falls-related injuries. There is a clinical requirement, therefore, to screen for and manage orthostatic hypotension in patients with Parkinson's disease to prevent falls, even in those who do not report typical symptoms.

Asymptomatic orthostatic hypotension and risk of falls in community-dwelling older people.

INTRODUCTION: Many older people with orthostatic hypotension (OH) may not report typical symptoms of dizziness, light-headedness or unsteadiness. However, the relationships between OH and falls in the absence of typical symptoms are not yet established. METHODS: Continuous orthostatic blood pressure (BP) was measured during active stand using a Finometer at Wave 1 of The Irish Longitudinal Study on Ageing in participants aged ≥ 70 years.OH, with and without dizziness, was defined as a sustained drop in systolic BP ≥ 20 and/or diastolic BP ≥ 10 mm Hg at 30, 60 and 90 seconds post-standing.The association between symptoms of dizziness and orthostatic BP was assessed with multi-level mixed-effects linear regression; logistic regression models assessed the longitudinal relationship between OH and falls at 6-year follow-up (Waves 2-5). RESULTS: Almost 11% (n = 934, mean age 75 years, 51% female) had OH, two-thirds of whom were asymptomatic.Dizziness was not associated with systolic BP drop at 30 (ß = 1.54 (-1.27, 4.36); p = 0.256), 60 (ß = 2.64 (-0.19, 5.47); p = 0.476) or 90 seconds (ß = 2.02 (-0.91, 4.95); p = 0.176) after standing in adjusted models.Asymptomatic OH was independently associated with unexplained falls (odds ratio 2.01 [1.11, 3.65]; p = 0.022) but not explained falls (OR 0.93 [0.53, 1.62]; p = 0.797) during follow-up. CONCLUSIONS: Two-thirds of older people with OH did not report typical symptoms of light-headedness. Dizziness or unsteadiness after standing did not correlate with the degree of orthostatic BP drop or recovery. Participants with asymptomatic OH had a significantly higher risk of unexplained falls during follow-up, and this has important clinical implications for the assessment of older people with falls.

Deprescribing practices, habits and attitudes of geriatricians and geriatricians-in-training across Europe: a large web-based survey.

PURPOSE: To provide an overview of the current deprescribing attitudes, practices, and approaches of geriatricians and geriatricians-in-training across Europe. METHODS: An online survey was disseminated among European geriatricians and geriatricians-in-training. The survey comprised Likert scale and multiple-choice questions on deprescribing approaches and practices, deprescribing education and knowledge, and facilitators/barriers of deprescribing. Responses to the survey questions and participant characteristics were quantified and differences evaluated between geriatricians and geriatricians-in-training and between European regions. RESULTS: The 964 respondents (median age 42 years old; 64% female; 21% geriatricians-in-training) were generally willing to deprescribe (98%) and felt confident about deprescribing (85%). Despite differences across European regions, the most commonly reported reasons for deprescribing were functional impairment and occurrence of adverse drug reactions. The most important barriers for deprescribing were patients' unwillingness, fear of negative consequences, lack of time, and poor communication between multiple prescribers. Perceived risk of adverse drug reactions was highest for psychotropic drugs, nonsteroidal anti-inflammatory drugs, cardiovascular drugs, and opioid analgesics. Only one in four respondents (23% of geriatricians and 37% of geriatricians-in-training) think education in medical school had sufficiently prepared them for deprescribing in clinical practice. They reported that their future deprescribing activities would probably increase with improved information sharing between various prescribers, deprescribing recommendations in guidelines, and increased education and training. Approximately 90% think that a paradigm shift is required for prescribers and patients, increasing focus on the possible benefits of deprescribing (potentially) inappropriate medications. CONCLUSIONS: Based on the outcomes of this survey, we recommend investing in improved inter-professional communication, better education and evidence-based recommendations to improve future patient-centered deprescribing practices.

Scoring the Clinical Frailty Scale in the Emergency Department: The Home FIRsT Experience.

We evaluated predictors of the Clinical Frailty Scale (CFS) scored by an interdisciplinary team (Home FIRsT) performing comprehensive geriatric assessment (CGA) in our Emergency Department (ED). This was a retrospective observational study (service evaluation) utilising ED-based CGA data routinely collected by Home FIRsT between January and October 2020. A linear regression model was computed to establish independent predictors of CFS. This was complemented by a classification and regression tree (CRT) to evaluate the main predictors. There were 799 Home FIRsT episodes, of which 740 were unique patients. The CFS was scored on 658 (89%) (median 4, range 1-8; mean age 81 years, 61% women). Independent predictors of higher CFS were older age (p<0.001), history of dementia (p<0.001), mobility (p≤0.007), disability (p<0.001), and higher acuity of illness (p=0.009). Disability and mobility were the main classifiers in the CRT. Results suggest appropriate CFS scoring informed by functional baseline.

A systematic scoping review of interventions to optimise medication prescribing and adherence in older adults with cancer.

BACKGROUND: Older adults with cancer often require multiple medications (polypharmacy) comprising cancer-specific treatments, supportive care medications (e.g. analgesics), and medications for pre-existing health conditions. Increasing numbers of medications may increase risks of potentially inappropriate prescribing and non-adherence. OBJECTIVE: To provide an overview of evaluations of interventions aimed at optimising medication prescribing and/or adherence in older adults with cancer. METHODS: A systematic scoping review was undertaken. Four databases (PubMed, EMBASE, CINAHL, PsycINFO) were searched using relevant search terms (e.g. cancer, older adults). Eligible studies evaluated interventions seeking to improve medication prescribing and/or adherence in older adults (≥65 years) with cancer using a comparative evaluation. All outcomes for studies that met inclusion criteria were included in the review. Extracted data were collated using tables and accompanying narrative descriptive summaries. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. RESULTS: Nine studies met inclusion criteria comprising five randomised controlled trials (RCTs) and four before-and-after study designs. Studies were primarily conducted in oncology clinics, ranging from single study sites to 109 oncology clinics. Sample sizes ranged between 33 and 4844 patients. Interventions most commonly involved patient education (n = 6) delivered by pharmacists or nurses. Three studies reported on prescribing-related outcomes and seven studies reported on adherence-related outcomes, using different terminology and assessment methods. Prescribing-related outcomes focused on medication appropriateness (using Beers criteria) and drug-related problems including drug interactions. Adherence-related outcomes included assessments of self-reported medication adherence and calculation of patients' medication possession ratio. CONCLUSIONS: This scoping review highlights a lack of robust evaluations of interventions aimed at optimising medication prescribing and adherence in older adults with cancer. Future research should improve rigour during intervention development, evaluation and reporting in order to generate findings that could inform future practice.

What factors are associated with advance care planning in community-dwelling older people? Data from TILDA.

PURPOSE: To assess advance care planning (ACP) in a large population-representative sample of older people. METHODS: At Wave 4 of the Irish Longitudinal Study on Ageing, participants were asked: Have you made your wishes/preferences known about the kind of care that you would like to receive in the event of serious illness? RESULTS: One quarter (1153/4831) had discussed ACP. Of those, 90% had discussed with family/friends, 10% documented ACP in writing, while 2% had discussed with a healthcare professional. Age ≥ 80 years [OR 1.63 (1.31-2.02)], female sex [OR 1.58 (1.37-1.83)], higher educational attainment [OR 1.42 (1.18-1.71)], poorer self-rated health [OR 1.67 (1.06-2.62)] and lower levels of religiosity [OR 1.50 (1.02-2.19)] were independently associated with ACP. CONCLUSION: Only one in four older people had discussed ACP informally, while less than 3% have ACP documented in writing. Further work is required to educate the public and healthcare professionals regarding treatment choices at end-of-life.

Trends in emergency department use by older people during the COVID-19 pandemic.

PURPOSE: Reports suggest that many older people deferred seeking healthcare during the COVID-19 pandemic due to fear of contracting COVID-19. The aim of this study was to examine trends of emergency department (ED) use by older people during the first wave of the COVID-19 pandemic compared to previous years. METHODS: The study site is a 1000-bed university teaching hospital with annual ED new-patient attendance of > 50,000. All ED presentations of patients aged ≥ 70 years from March to August 2020, 2019 and 2018 inclusive (n = 13,989) were reviewed and compared for presenting complaint, Manchester Triage Score, and admission/discharge decision. RESULTS: There was a 16% reduction in presentations across the 6 months in 2020 compared to the average of 2018/2019. On average, 4 fewer people aged ≥ 70 years presented to the ED per day in 2020. Much of this was concentrated in March (33% fewer presentations) and April (31% fewer presentations), when the country was in 'lockdown', i.e. non-essential journeys were banned. There was a 20% reduction in patients presenting with stroke and cardiac complaints. In the 3 months following easing of restrictions, there was a 25% increase in falls and orthopaedic injuries when compared to 2018/2019. CONCLUSION: This study demonstrates a significant decline in the number of older people presenting to the ED for unscheduled care, including for potentially time-dependent illnesses such as stroke or cardiac complaints. Given the possibility of further lockdowns, it is imperative that we consider enabling strategies to ensure older people access unscheduled care in a timely manner when necessary.

Potentially inappropriate medication (PIM) use and severe drug interactions (SDIs) in older adults with cancer.

BACKGROUND: Older adults with cancer frequently have other co-morbidities requiring prescription pharmacotherapy. The objectives of this study were to identify the prevalence of potentially inappropriate medications (PIMs), severe drug interactions (SDIs) and associated risk factors in these patients. MATERIALS AND METHODS: This twelve-month prospective observation study was conducted at an Irish Hospital. PIMs were identified in older adults (≥65 years) using STOPP and OncPal criteria; potential SDIs using Stockley's interaction checker. RESULTS: We enrolled 186 patients; mean age 72.5(SD5.7) years, 46.2% female, mean co-morbidities 7.5(SD3.4), median medications 7(IQR4-9). Polypharmacy (≥6 medications) and major polypharmacy (≥11 medications) were identified in 60.8% and 17.7% respectively. STOPP PIMs were observed in 73.1%; median 2(IQR1-3). The most common PIM identified was any drug prescribed beyond the recommended duration (46.5%). For each additional prescription, the odds of receiving a STOPP PIM increased by 79.2% (OR 1.792, 95% CI 1.459-2.02). Potential SDIs were identified in 50.5% participants. The most common were beta-blocker/alpha-blocker (6.5%), selective-serotonin re-uptake inhibitor (SSRI)/proton pump inhibitor (PPI) (5.9%) and SSRI/Aspirin (4.8%). For each additional prescription, the odds of an SDI increased by 50.8% (OR 1.508, 95% CI 1.288-1.764). Seventy-seven (41.4%) participants died within six months of enrolment. OncPal PIMs were observed in 81.8% of this cohort, median 2(IQR1-3). The most common OncPal PIM was statin therapy (38%). For each additional prescription, the odds of receiving an OncPal PIM increased by 38.2%, (OR 1.382, 95% CI 1.080-1.767). CONCLUSIONS: PIMs and SDIs are common in this population. Comprehensive specialist evaluation of medications by a geriatrician may identify PIMs thereby reducing related adverse outcomes such as SDIs.

Delayed Blood Pressure Recovery After Standing Independently Predicts Fracture in Community-Dwelling Older People.

OBJECTIVES: Orthostatic hypotension, characterized by delayed blood pressure (BP) recovery after standing, is a risk factor for falls but the longitudinal relationship with fracture is not yet known. The aim of this study was to examine the prospective risk of fracture associated with delayed BP recovery. DESIGN: Longitudinal study with 8-year follow-up. SETTING AND PARTICIPANTS: More than 3000 (54% female) community-dwelling people aged ≥50 years from a large longitudinal study on ageing. METHODS: Orthostatic BP was measured using a finometer when standing from lying. Delayed BP recovery was defined as systolic BP ≥20 mm Hg lower and/or diastolic BP ≥10 mm Hg from the baseline value at 30, 60, and 90 seconds after standing. Participants with a fracture reported at any of waves 2 to 5 were defined as having incident fracture. Logistic regression models were used to estimate odds ratios (ORs) for the association between delayed BP recovery and incident fracture. RESULTS: Seven percent (212/3117) of participants sustained a fracture during follow-up. Delayed BP recovery at 30 seconds was a significant predictor of any fracture [OR 1.80, 95% confidence interval (CI) 1.28-2.53] and hip fracture (OR 4.44, 95% CI 2.03-9.71) in fully adjusted models. Delayed BP recovery at 30 seconds did not predict wrist or vertebral fracture. Delayed BP recovery at 60 seconds also predicted any fracture (OR 1.74, 95% CI 1.19-2.54) and hip fracture (OR 4.66, 95% CI 2.12-10.26) whereas delayed BP recovery at 90 seconds predicted any (OR 1.99, 95% CI 1.38-2.87), wrist (OR 1.87, 95% CI 1.19-2.95), and hip fracture (OR 3.39, 95% CI 1.45-7.93) in fully adjusted models. CONCLUSION: and Implications: Delayed BP recovery independently predicts fracture in community-dwelling older people, is potentially modifiable, and can be measured in an ambulatory setting. Because of the morbidity and mortality associated with fractures, identification of such risk factors is crucial in order to inform preventative strategies.

Prevention of adverse drug reactions in hospitalized older patients with multi-morbidity and polypharmacy: the SENATOR* randomized controlled clinical trial.

BACKGROUND: Multi-morbidity and polypharmacy increase the risk of non-trivial adverse drug reactions (ADRs) in older people during hospitalization. Despite this, there are no established interventions for hospital-acquired ADR prevention. METHODS: We undertook a pragmatic, multi-national, parallel arm prospective randomized open-label, blinded endpoint (PROBE) controlled trial enrolling patients at six European medical centres. We randomized 1,537 older medical and surgical patients with multi-morbidity and polypharmacy on admission in a 1:1 ratio to SENATOR software-guided medication optimization plus standard care (intervention, n = 772, mean number of daily medications = 9.34) or standard care alone (control, n = 765, mean number of daily medications = 9.23) using block randomization stratified by site and admission type. Attending clinicians in the intervention arm received SENATOR-generated advice at a single time point with recommendations they could choose to adopt or not. The primary endpoint was occurrence of probable or certain ADRs within 14 days of randomization. Secondary endpoints were primary endpoint derivatives; tertiary endpoints included all-cause mortality, re-hospitalization, composite healthcare utilization and health-related quality of life. RESULTS: For the primary endpoint, there was no difference between the intervention and control groups (24.5 vs. 24.8%; OR 0.98; 95% CI 0.77-1.24; P = 0.88). Similarly, with secondary and tertiary endpoints, there were no significant differences. Among attending clinicians in the intervention group, implementation of SENATOR software-generated medication advice points was poor (~15%). CONCLUSIONS: In this trial, uptake of software-generated medication advice to minimize ADRs was poor and did not reduce ADR incidence during index hospitalization.

Interventions to optimise medication prescribing and adherence in older people with cancer: A systematic scoping review.

BACKGROUND: Older adults with cancer often require multiple medications including cancer-specific treatments and supportive care medications (e.g. analgesics), as well as medications for pre-existing medical conditions. Increasing numbers of medications pose risks of potentially inappropriate prescribing, drug-drug interactions and drug-disease interactions. The burden of treatment (i.e. the workload of healthcare and its impact on patient functioning and well-being) may also negatively affect the way patients take their medications. Non-adherence to medication in patients with cancer is associated with treatment failure and increased healthcare costs. Therefore, it is crucial that medicines are optimised for older adults with cancer to enhance appropriate prescribing, reduce the complexity of treatment regimens and minimise the risk of non-adherence. OBJECTIVE: To provide an overview of evaluations of interventions aimed at optimising medication prescribing and/or adherence in older adults with cancer. METHODS: A systematic scoping review will be undertaken. Four databases will be searched from inception: PubMed, EMBASE, CINAHL and PsycINFO. In order to meet inclusion criteria, studies must evaluate an intervention seeking to improve medication prescribing and/or adherence in older adults (aged ≥65 years) with an active cancer diagnosis using a comparative evaluation (e.g. inclusion of a control group). Two reviewers will independently screen titles and abstracts for inclusion and extract data relating to study population, intervention characteristics, outcome assessments and key findings. Extracted data will be collated using tables, figures and accompanying descriptive summaries. The review will be reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. PROJECT IMPACT: The scoping nature of this review will serve to provide an overview of the existing literature on interventions aimed at optimising medication prescribing and adherence in older adults with cancer. The review findings will help to identify research gaps and highlight areas to explore further in future research.

Reducing inappropriate prescribing for older adults with advanced frailty: A review based on a survey of practice in four countries.

The management of medications in persons with frailty presents challenges. There is evidence of inappropriate prescribing and a lack of consensus among healthcare professionals on the judicious use of medications, particularly for patients with more severe frailty. This study reviews the evidence on the use of commonly prescribed pharmacological treatments in advanced frailty based on a questionnaire of prescribing practices and attitudes of healthcare professionals at different stages in their careers, in different countries. A convenience sample of those attending hospital grand rounds in Ireland, Canada and Australia/New Zealand (ANZ) were surveyed on the management of 18 medications in advanced frailty using a clinical vignette (man with severe dementia, Clinical Frailty Scale 7/9). Choices were to continue or discontinue (stop now or later) medications. In total, 298 respondents from Ireland (n = 124), Canada (n = 110), and ANZ (n = 64) completed the questionnaire, response rate 97%, including 81 consultants, 40 non-consultant hospital doctors, 134 general practitioners and 43 others (nurses, pharmacists, and medical students). Most felt that statins (88%), bisphosphonates (77%) and cholinesterase inhibitors (76%) should be discontinued. Thyroid replacement (88%), laxatives (83%) and paracetamol (81%) were most often continued. Respondents with experience in geriatric, palliative and dementia care were significantly more likely to discontinue medications. Age, gender and experience working in nursing homes did not contribute to the decision. Reflecting the current literature, there was no clear consensus on inappropriate prescribing, although respondents preferentially discontinued medications for secondary prevention. Experience significantly predicted the number and type discontinued, suggesting that education is important in reducing inappropriate prescribing for people in advanced states of frailty.

Adverse Drug Reactions in an Oncological Population: Prevalence, Predictability, and Preventability.

BACKGROUND: Our goal was to determine (a) the prevalence of multimorbidity and polypharmacy in patients with cancer and (b) the prevalence, predictability, and preventability of adverse drug reactions (ADRs) causing/contributing to hospitalization. MATERIALS AND METHODS: We conducted a 12-month prospective observational study of patients aged ≥16 years admitted to an oncology center. Older adults were aged ≥70 years. RESULTS: We enrolled 350 patients: 52.3% (n = 183) female, mean age 63.6 years (SD 12.1), 36.6% (n = 121) aged ≥70 years. Multimorbidity (≥2 conditions) was identified in 96.9%; 68% had ≥5 conditions. The median number of medications was 6 (interquartile range [IQR] 4-8); 47% were prescribed ≥6 medications and 11.4% ≥11 medications. Older adults had higher numbers of comorbid conditions (7 [IQR 5-10] vs. 5 [IQR 3-7]) and were prescribed more medications (median 7 [IQR 4-9] vs. 4 [IQR 2-7]). ADRs caused/contributed to hospitalization in 21.5% (n = 75): 35.8% (n = 72) of emergency admissions and 4.7% (n = 3) of elective admissions. The most common ADRs were neutropenia with infection (25.3%), dyspepsia/nausea/vomiting (20%), and constipation (20%). Causative medications included systemic anticancer therapies (SACTs; 53.3%), opioids (17.3%), corticosteroids (6.7%), and nonsteroidal anti-inflammatory drugs (5.3%). ADR prevalence was similar in older and younger adults secondary to SACTs (8.3% vs. 13.1%), non-cancer medications (10.7% vs. 8.3%), and both (0% vs. 1.3%). ADRs were predictable in 89.3% (n = 67), definitely avoidable in 29.3% (n = 22), and possibly avoidable in 33.3% (n = 25). No association was identified between ADRs and age, gender, daily medication number, length of stay, or death. No ADR predictor variables were identified by logistic regression. CONCLUSION: More than 21% of admissions to an oncology service are ADR-related. ADRs are caused by both SACTs and non-cancer-specific medications. The majority are predictable; ≥60% may be preventable. Patients with cancer have high levels of multimorbidity and polypharmacy, which require vigilance for related adverse outcomes. IMPLICATIONS FOR PRACTICE: A diagnosis of cancer often occurs in patients with multimorbidity and polypharmacy. Cancer can cause an altered physiological environment, placing patients at risk of drug-drug interactions, drug-disease interactions, and adverse drug reactions (ADRs). This study identified that ADRs caused or contributed to one in five hospital admissions of patients with cancer. ADRs were caused by systemic anticancer therapies (SACTs) in 53.3% of cases and non-cancer medications in 45.4% of cases, and a combination of both in 1.3%. ADRs occurred in similar frequencies in older and younger patients secondary to SACTs (8.3% vs. 13.1%, p = .295), non-SACTs (10.7% vs. 8.3%, p = .107), and a combination of both (0% vs. 1.3%, p = .240). The majority of ADRs were predictable (89.3%) and potentially preventable (62.6%). These findings support the need for increased awareness of medication-related adversity in patients with cancer and interventions to minimize their occurrence, thus supporting the American Society of Clinical Oncology guidelines that recommend adults ≥65 years of age receiving chemotherapy have geriatric assessment to identify medical and medication issues.

The effect of SENATOR (Software ENgine for the Assessment and optimisation of drug and non-drug Therapy in Older peRsons) on incident adverse drug reactions (ADRs) in an older hospital cohort - Trial Protocol.

BACKGROUND: The aim of this trial is to evaluate the effect of SENATOR software on incident, adverse drug reactions (ADRs) in older, multimorbid, hospitalized patients. The SENATOR software produces a report designed to optimize older patients' current prescriptions by applying the published STOPP and START criteria, highlighting drug-drug and drug-disease interactions and providing non-pharmacological recommendations aimed at reducing the risk of incident delirium. METHODS: We will conduct a multinational, pragmatic, parallel arm Prospective Randomized Open-label, Blinded Endpoint (PROBE) controlled trial. Patients with acute illnesses are screened for recruitment within 48 h of arrival to hospital and enrolled if they meet the relevant entry criteria. Participants' medical history, current prescriptions, select laboratory tests, electrocardiogram, cognitive status and functional status are collected and entered into a dedicated trial database. Patients are individually randomized with equal allocation ratio. Randomization is stratified by site and medical versus surgical admission, and uses random block sizes. Patients randomized to either arm receive standard routine pharmaceutical clinical care as it exists in each site. Additionally, in the intervention arm an individualized SENATOR-generated medication advice report based on the participant's clinical and medication data is placed in their medical record and a senior medical staff member is requested to review it and adopt any of its recommendations that they judge appropriate. The trial's primary outcome is the proportion of patients experiencing at least one adjudicated probable or certain, non-trivial ADR, during the index hospitalization, assessed at 14 days post-randomization or at index hospital discharge if it occurs earlier. Potential ADRs are identified retrospectively by the site researchers who complete a Potential Endpoint Form (one per type of event) that is adjudicated by a blinded, expert committee. All occurrences of 12 pre-specified events, which represent the majority of ADRs, are reported to the committee along with other suspected ADRs. Participants are followed up 12 (+/- 4) weeks post-index hospital discharge to assess medication quality and healthcare utilization. This is the first clinical trial to examine the effectiveness of a software intervention on incident ADRs and associated healthcare costs during hospitalization in older people with multi-morbidity and polypharmacy. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov NCT02097654 , 27 March 2014.

STOPPFrail (Screening Tool of Older Persons' Prescriptions in Frail adults with a limited life expectancy) criteria: application to a representative population awaiting long-term nursing care.

PURPOSE: STOPPFrail criteria highlight instances of potentially inappropriate medications (PIMs) in frailer older adults with poor 1-year survival prognosis. The objectives of this study were to (i) determine the proportion of older adults requiring long-term nursing care in whom STOPPFrail criteria are applicable, (ii) measure the prevalence of STOPPFrail PIMs, and (iii) identify risk factors for PIMs in this cohort. METHODS: We retrospectively reviewed applications for long-term nursing care to nursing homes in the Cork area over a 6-month period. We recorded diagnoses, medications, functional status, cognitive ability, frailty status, and applied STOPPFrail criteria as appropriate. RESULTS: We reviewed 464 applications; 38 were excluded due to incomplete information and 274 patients (64.3%) met STOPPFrail eligibility criteria (median age 83 years (IQR 77.25-88); 233 (54.7%) female). Those STOPPFrail eligible were prescribed 2194 medications (mean 8, (SD 4)), of which 828 (37.7%) were PIMs. At least one PIM was identified in 250 eligible patients (91.2%). The median number of PIMs was 3 (IQR 2-4), the most common being (i) medications without clear indication identified in 47.0% (n = 129) of patients, (ii) long-term high-dose proton pump inhibitors in 31.4% (n = 86), and (iii) statins in 29.6% (n = 81). For every additional medication prescribed, the odds of identifying a PIM increased by 58% (odds ratio 1.58, 95% CI 1.32-1.89, p < 0.001). CONCLUSION: Almost 65% of patients awaiting long-term care are eligible for the application of STOPPFrail criteria with over 90% prescribed at least one PIM. Transition to nursing home care represents an opportunity to review therapeutic appropriateness and goals of prescribed medications.

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 (χ2 = 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.

Inter-rater reliability of STOPPFrail [Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy] criteria amongst 12 physicians.

PURPOSE: STOPPFrail is an explicit tool, developed by Delphi consensus, to assist physicians with deprescribing medications in frail older adults with poor survival prognosis. This study aimed to determine the inter-rater reliability (IRR), amongst physicians, of STOPPFrail application. METHODS: Twenty clinical cases were collated to represent frail older patients. Eighteen cases met STOPPFrail inclusion criteria. They had a mean age of 79.5 (SD6) years and a median of 7 (IQR6-8.25) comorbidities and were prescribed a median of 9 (IQR7.75-11.25) medications. Two of the STOPPFrail originators reached complete agreement (gold standard) in determining 91 of 165 medications (55.2%) as inappropriate. Twelve physicians (6 geriatricians, 3 general practitioners and 3 palliative care physicians) independently applied STOPPFrail criteria. IRR between physicians and gold standard (GS) assessment was determined using Cohen's kappa statistic. RESULTS: Eighteen of the 20 cases that met STOPPFrail inclusion criteria were correctly identified by 9 of 12 physicians (75%). The average time taken per clinical case was 2.7 (SD0.94) minutes. The kappa co-efficient between physicians and GS assessment ranged from 0.71 (substantial) to 0.86 (good), with a mean kappa value of 0.758 (SD0.059). The Fleiss kappa coefficients between GS assessment and geriatricians, GPs and palliative care physicians were 0.80 (SD0.6), 0.77 (SD0.9) and 0.75 (SD0.1), respectively. No significant difference was noted, between groups or between participants within groups, as determined by one-way ANOVA, (df (2, 9) = 0.712, p = 0.516). CONCLUSIONS: IRR of STOPPFrail criteria between physicians, practising in different specialties, is substantial, despite no prior knowledge of the criteria.