Optimizing medical care for geriatric patients in Austria: defining a top five list of "Choosing Wisely" recommendations using the Delphi technique.

PURPOSE: Inappropriate use of diagnostic and therapeutic medical procedures is common and potentially harmful for older patients. The Austrian Society of Geriatrics and Gerontology defined a consensus of five recommendations to avoid overuse of medical interventions and to improve care of geriatric patients. METHODS: From an initial pool of 147 reliable recommendations, 20 were chosen by a structured selection process for inclusion in a Delphi process to define a list of five top recommendations for geriatric medicine. 12 experts in the field of geriatric medicine scored the recommendations in two Delphi rounds. RESULTS: The final five recommendations are concerning urinary catheters in elderly patients, percutaneous feeding tubes in patients with advanced dementia, antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia, and screening for breast, colorectal, prostate, or lung cancer, and the use of antimicrobials to treat asymptomatic bacteriuria. CONCLUSIONS: The selected recommendations have the potential to improve medical care for older patients, to reduce side effects caused by unnecessary medical procedures, and to save costs in the health care system.

DEL-FINE: a new tool for assessing the delirogenic properties of drugs of relevance for European pharmacotherapy.

This article presents a list of potentially delirogenic properties of drugs that are currently of relevance to drug therapy in Europe, which was created through a Delphi process including experts from professions relevant to diagnosis and treatment of delirium. The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) defines delirium as a disturbance in attention, awareness and cognition that develops over a short period of time and fluctuates. Possible causes of delirium are manifold: usually delirium is considered to develop in a multifactorial way, caused by inalterable parameters, such as advanced age and pre-existing cognitive impairment and precipitated by modifiable parameters, such as the use of certain drugs or substance withdrawal. Delirium is a serious condition with a pronounced impact on morbidity, mortality and costs to the healthcare system. Circumstances and drugs that might precipitate or worsen delirium should therefore be avoided whenever possible. A list of drugs that might have a detrimental influence on the emergence and duration of delirium has been created using the terms "delirogenity" and "delirogenic" to describe the potential of a drug or withdrawal to cause or worsen delirium. The results are novel and noteworthy, as their focus is on substances relevant to European pharmacotherapy. Furthermore, they represent a methodical consensus from a group of experts of a wide variety of professions relevant to the prevention, diagnosis and treatment of delirium, such as nursing, pharmacy, pharmacology, surgical and internal medicine, neurology, psychiatry, intensive care and medicine, with working, teaching and scientific experience in several European countries practicing both in primary and secondary care.

[Polypharmacy is of major concern in cardiology]. / Polypharmazie in der Kardiologie - ein beachtliches Problem bei Synkopen, QT-Zeit-Verlängerung, Bradykardie und Tachykardie.

Quality improvement in cardiology over the past decade focused on management of acute coronary syndrome with invasive and innovative medical therapies, optimizing treatment of congestive heart failure and the development of repair procedures in valvular heart disease. On the other hand cardiologist and the attendant physicians are confronted with changes in the characteristics of patients in the light of demographic facts. Comorbidity and polypharmacy raise the need for clear concepts. Therapeutic and diagnostic tools of geriatric medicine may help in that context.

[Oral anticoagulation and risk of bleeding in elderly patients - the aspect of polypharmacy]. / Blutungskomplikationen bei geriatrischen Patienten unter oraler Antikoagulation - Aspekte der Polypragmasie.

Oral anticoagulant therapy has been shown to be of benefit also in elderly patients in various therapeutic and prophylactic indications. Despite strong evidence in literature, doctors still refuse to prescribe oral anticoagulants to geriatric patients in daily routine. Main reason for this decision is the fear of secondary bleeding complications. According to clinical trial data, distinct risk factors for bleeding attributed to anticoagulant treatment may be determined: age >70 years, female gender, recurrent bleeding events, alcohol/drug abuse, diabetes, anaemia and polypharmacy. The entire article reveals the literature in Medline and Cochrane Library from 1980 to 2009 including the hits "polypharmacy - anticoagulant treatment - elderly patients". It further highlights risk assessment strategies in elderly patients, and possible pharmacokinetic and -dynamic interactions of drugs co-administered with oral anticoagulants.

[Diuretics-related complications in elderly patients]. / Komplikationen durch Diuretikatherapie bei geriatrischen Patienten.

Diuretics are well studied and evaluated for their beneficial use in geriatric patients. However those drugs are often used without taking care of subjects condition or functional impairment. Known side effects of those substances may be increased by combinations of multiple drugs. Polypharmacy is a strong risk factor for the incidence of adverse drug reactions (ADR). ADRs are frequently found in combination with the use of diuretics. The remodelling of human body in aging process and uncontrolled therapeutic strategies seem to be causal for that finding. This article tries to work out the potential risk of the usage of those drugs in geriatric patients and its clinical relevance by using literature published in PubMed.

[Drug-related delirium in elderly patients]. / Medikamenten-induzierte Delirien älterer Menschen.

Drugs have been widely associated with the development of delirium in the elderly and represent the most common reversible cause of this condition. This is of importance since successful treatment depends on identifying the reversible contributing factors. Medications with anticholinergic properties, tranquilizers, analgesics and narcotics are common causes of drug-induced delirium. This article provides practical approach to prevent and recognise this condition, reviews the underlying neurotransmitter imbalances and reconsiders age-related changes of pharmacological effects, which may contribute to the development of delirium.

[Polypharmacy and pain treatment]. / Polypharmazie und Schmerztherapie.

Pain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug-drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.

[Polypharmacy and falls in the Elderly]. / Polypharmazie und Stürze im Alter.

Falls and their consequences are a major problem in geriatric medicine. Main causes are the combination of age-related physiological changes with multimorbidity and subsequent polypharmacy. Elderly patients are more susceptible to adverse drug effects and have less compensatory capacity than younger adults. Therefore careful monitoring of side effects is indicated and prescribing for elderly patients calls for alertness in order to identify symptoms as possible adverse drug effects.

Influence of a complex micronutrient supplement on the immune status of elderly individuals.

Nutritional status is known to have profound effects on immune function and resistance to infections, particularly in the elderly. We investigated the effect of a complex micronutrient supplement in elderly people on the changes in some of the cellular components of the immune system, on lymphocyte function, and on the antibody response to influenza vaccination. One-hundred-six subjects aged 62 to 98 were randomly assigned to receive a complex micronutrient supplement or a placebo for three months. Subjects were vaccinated against influenza after eight weeks. Clinical parameters, lymphocyte subsets, in vitro lymphocyte activation, and influenza antibody titers were assessed at baseline and after 90 days of supplementation. A significant increase in total lymphocytes (p=0.034) and white blood cells (WBC) (p=0.03) in the supplemented group was observed. A shift from CD4+/CD45RO+ "memory" cells to CD4+/CD45RA+ "naïve" T-cells in favor of CD4+/CD45RA+ "naïve" T-cells took place. The group consuming additional micronutrients showed an increase in CD45RA+ subsets (p=0.032) compared to the control group. A decrease of total cholesterol (from 228.72 + or - 56.11 to 210.74 + or - 52.58, p=0.002) and low-density lipoprotein (LDL) (from 145.75 + or - 48.86 to 125.47 + or - 41.72, p<0.001) was observed. Influenza antibody titers showed no correlation with micronutrient intake. We conclude that supplementation with a complex micronutrient formulation increases the number of various types of immune cells and decreases total cholesterol and LDL in elderly people. No beneficial effect on specific antibody response to influenza vaccination was observed. Further research is needed to evaluate whether enhanced cellular immune responses decrease the incidence of infections in elderly people.