Potentially severe drug-drug interactions among older people and associations in assisted living facilities in Finland: a cross-sectional study.

OBJECTIVE: This study aims to assess potentially severe class D drug-drug interactions (DDDIs) in residents 65 years or older in assisted living facilities with the use of a Swedish and Finnish drug-drug interaction database (SFINX). DESIGN: A cross-sectional study of residents in assisted living facilities in Helsinki, Finland. SETTING: A total of 1327 residents were assessed in this study. Drugs were classified according to the Anatomical Therapeutic Chemical (ATC) classification system and DDDIs were coded according to the SFINX. MAIN OUTCOME MEASURES: Prevalence of DDDIs, associated factors and 3-year mortality among residents. RESULTS: Of the participants (mean age was 82.7 years, 78.3% were females), 5.9% (N = 78) are at risk for DDDIs, with a total of 86 interactions. Participants with DDDIs had been prescribed a higher number of drugs (10.8 (SD 3.8) vs. 7.9 (SD 3.7), p < 0.001). A larger proportion of residents with DDDIs suffered from rheumatoid arthritis or osteoarthritis than those not exposed to DDDIs (24.7% vs. 15.4%, p = 0.030). The most frequent DDDIs were related to the concomitant use of potassium with amiloride (N = 12) or spironolactone (N = 12). Carbamazepine (N = 13) and methotrexate (N = 9) treatments were also frequently linked to DDDIs. During the follow-up, no differences in mortality emerged between the participants exposed to DDDIs and the participants not exposed to DDDIs. CONCLUSIONS: Of the residents in assisted living, 5.9% were exposed to DDDIs associated with the use of a higher number of drugs. Physicians should be trained to find safer alternatives to drugs associated with DDDIs. KEY POINTS Potentially severe, class D drug-drug interactions (DDDIs) have been defined in the SFINX database as clinically relevant drug interactions that should be avoided. • Of the residents in assisted living, 5.9% were exposed to DDDIs that were associated with the use of a higher number of drugs. • The most frequent DDDIs were related to the concomitant use of potassium with amiloride or spironolactone. Carbamazepine and methotrexate were also linked to DDDIs. • No difference in mortality was observed between residents exposed to DDDIs and residents not exposed to DDDIs.

Eight-Year Trends in the Use of Opioids, Other Analgesics, and Psychotropic Medications Among Institutionalized Older People in Finland.

IMPORTANCE: It is recognized that pain has been undertreated and psychotropic medications overused in institutional settings. OBJECTIVE: To investigate the change in prevalence of opioids, other analgesics, and psychotropic medications in institutional settings over an 8-year period. SETTINGS: Institutional settings in Helsinki, Finland. PARTICIPANTS: Older residents in nursing homes in 2003 (n = 1987) and 2011 (n = 1576) and in assisted living facilities in 2007 (n = 1377) and 2011 (n = 1586). OUTCOME MEASURES: Comparable audits of medication use were conducted among institutionalized residents at 3 time points over 8 years. The prevalence of regular opioid, other analgesic, and psychotropic medications was compared across the 3 time periods. RESULTS: Nursing home and assisted living facility residents were older; more disabled, had a higher prevalence of dementia, and greater comorbidity in the latter cohorts. The prevalence of regular opioid use was 11.8% and 22.9% in nursing homes in 2003 and 2011 (P < .001), and 8.6% and 17.3% in assisted living facilities in 2007 and 2011 (P < .001), respectively. The prevalence of regular acetaminophen and pregabalin/gabapentin increased and NSAIDs decreased in both nursing homes and assisted living facilities. The prevalence of regular antipsychotic use decreased from 42.6% to 27.8% in nursing homes (P < .001) but increased from 26.9% to 32.0% in assisted living facilities (P = .0017). The mean number of psychotropic medications (antipsychotics, antidepressants, anxiolytics, hypnotics) per resident decreased from 1.9 in 2003 to 1.0 in 2011 in nursing homes (P < .001) but increased from 1.1 to 1.2 in assisted living facilities (P = .040). CONCLUSIONS: The prevalence of opioid use in institutional settings has doubled during the past decade. The prevalence of psychotropic medications has decreased in nursing homes but increased in assisted living facilities. The increase in opioid use may reflect improved recognition and treatment of pain. However, initiatives are needed to monitor opioid-related adverse drug events and ensure appropriate use of psychotropic medications, particularly in assisted living facilities.

Reducing inappropriate, anticholinergic and psychotropic drugs among older residents in assisted living facilities: study protocol for a randomized controlled trial.

BACKGROUND: Use of inappropriate drugs is common among institutionalized older people. Rigorous trials investigating the effect of the education of staff in institutionalized settings on the harm related to older people's drug treatment are still scarce. The aim of this trial is to investigate whether training professionals in assisted living facilities reduces the use of inappropriate drugs among residents and has an effect on residents' quality of life and use of health services. METHODS AND DESIGN: During years 2011 and 2012, a sample of residents in assisted living facilities in Helsinki (approximately 212) will be recruited, having offered to participate in a trial aiming to reduce their harmful drugs. Their wards will be randomized into two arms: one, those in which staff will be trained in two half-day sessions, including case studies to identify inappropriate, anticholinergic and psychotropic drugs among their residents, and two, a control group with usual care procedures and delayed training. The intervention wards will have an appointed nurse who will be responsible for taking care of the medication of the residents on her ward, and taking any problems to the consulting doctor, who will be responsible for the overall care of the patient. The trial will last for twelve months, the assessment time points will be zero, six and twelve months. The primary outcomes will be the proportion of persons using inappropriate, anticholinergic, or more than two psychotropic drugs, and the change in the mean number of inappropriate, anticholinergic and psychotropic drugs among residents. Secondary endpoints will be, for example, the change in the mean number of drugs, the proportion of residents having significant drug-drug interactions, residents' health-related quality of life (HRQOL) according to the 15D instrument, cognition according to verbal fluency and clock-drawing tests and the use and cost of health services, especially hospitalizations. DISCUSSION: To our knowledge, this is the first large-scale randomized trial exploring whether relatively light intervention, that is, staff training, will have an effect on reducing harmful drugs and improving QOL among institutionalized older people. TRIAL REGISTRATION: ACTRN12611001078943.

Risk of death associated with use of PPIs in three cohorts of institutionalized older people in Finland.

OBJECTIVES: To (1) explore clinical and demographic characteristics of users and nonusers of PPIs in 3 cohorts of institutionalized older people in Finland, and (2) compare the risk of death associated with use of PPIs in each setting. DESIGN: Cross-sectional assessment of 3 institutionalized cohorts with 1-year follow-up of all-cause mortality. SETTING AND PARTICIPANTS: A total of 1389 residents of 69 assisted living facilities (first cohort), 1004 residents of long term care hospitals (second cohort), and 425 residents in acute geriatric wards or in nursing homes (third cohort). MEASUREMENTS: Demographic, drug use, and diagnostic data were collected during structured assessments conducted by trained nurses or geriatricians. Cox proportional hazards models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between use of PPIs and mortality. RESULTS: In the assisted living facility, the mortality was 20.2% (n = 74) and 20.4% (n = 208) among users and nonusers of PPIs, respectively (P = 0.94). PPIs were not associated with mortality in unadjusted or adjusted analyses. In the long term care hospitals, use of PPIs was associated with increased mortality (HR, 1.36; 95% CI 1.04-1.77) when adjusted for age, sex, comorbidity, use of SSRIs, and malnutrition. In the acute geriatric wards and nursing homes, use of PPIs was associated with increased mortality (HR, 1.90; 95% CI 1.23-2.94) when adjusted for age, sex, comorbidity, delirium, and use of aspirin and SSRIs. CONCLUSION: PPIs were not associated with mortality among residents in assisted living facilities, but were associated with increased mortality in settings where residents experienced higher levels of disability and possible susceptibility to adverse drug events.

Use of anticholinergic drugs and cholinesterase inhibitors and their association with psychological well-being among frail older adults in residential care facilities.

BACKGROUND: Drugs with anticholinergic properties have harmful effects among frail older people and they may antagonize the effects of cholinesterase inhibitors (ChEIs). However, their association with psychological well-being has not been studied. OBJECTIVE: To determine (1) the prevalence of the use of anticholinergic drugs, ChEIs, or their combination among older adults in residential care facilities and their association with psychological well-being, and (2) the association of anticholinergic drugs with an individual's psychological well-being. METHODS: In 2007, all older adults (N = 1475) living in residential care facilities in the cities of Helsinki and Espoo, Finland, were assessed in a cross-sectional study. A trained nurse retrieved data on demographic factors, regularly administered medications, and diagnoses from medical charts. Psychological well-being was assessed using 6 questions concerning life satisfaction, zest for life, plans for the future, feeling needed, and feeling depressed or lonely, and a psychological well-being score was created (range 0-1). RESULTS: Residents taking anticholinergic drugs (n = 613) were significantly younger, used more drugs, and were more often on ChEIs compared with nonusers (n = 862). There was no significant difference in Charlson comorbidity index, stage of cognition, or dependence on activities of daily living between the users or nonusers of anticholinergic drugs. The anticholinergic drug users had significantly lower psychological well-being scores compared with the nonusers. Of the participants, 10.7% used ChEIs and anticholinergic drugs concomitantly. In logistic regression analysis where age, sex, comorbidities, and use of ChEIs were used as covariates, lower psychological well-being was associated with the use of anticholinergic drugs (OR 1.40; 95% CI 1.00 to 1.94; p = 0.048). CONCLUSIONS: Concomitant use of anticholinergic drugs and ChEIs is common among older adults. The use of anticholinergic drugs is associated with poor psychological well-being.

Use of proton-pump inhibitors and their associated risks among frail elderly nursing home residents.

OBJECTIVE: The aim of this study is to investigate the use of proton-pump inhibitors (PPI) and their associated risks among frail elderly nursing home residents. DESIGN: A cross-sectional study. SETTING: General practice. SUBJECTS: An assessment of residents (n = 1987, mean age 83.7 years) in all nursing homes in Helsinki was carried out in February 2003. Data included demographic characteristics, symptoms such as diarrhea, vomiting and constipation, use of various drugs, and medical diagnoses. OUTCOME: Coded data analysis with NCSS statistical program. Multivariate logistic regression analysis served to determine which variables were independently associated with diarrhea; variables which were statistically significant or near p < 0.05 in univariate analyses were included. RESULTS: Altogether 433 residents were on PPIs. The factors associated with regular PPI use in univariate analyses included poor functional status, higher number of comorbidities, higher number of medications and lactose intolerance. The users had suffered from a prior ventricular or duodenal ulcer, cancer and coronary heart disease more often than the non-users. In accordance with our hypothesis, the users of PPIs more often had diarrhea (19.7%) than the non-users (12.9%) (p < 0.001), and they had a prior hip fracture (28.5%) more often than the non-users (19.4%) (p < 0.001). In logistic regression analysis the use of PPIs had an independent association with diarrhea (OR 1.60 (95% CI 1.20 to 2.15). CONCLUSION: Physicians should avoid unnecessary long-term use of PPIs, particularly among frail elderly long-term care patients.