Electronic assessment of cardiovascular potentially inappropriate medications in an administrative population database.

AIM: To explore the feasibility of the electronic assessment of potentially inappropriate medication (PIM) criteria in a large administrative database and to explore the validity of the cardiovascular subset of PIM criteria, by studying the association with relevant outcome. METHOD: A cohort study using administrative data from Stockholm County, Sweden (VAL database). Eligible for inclusion were community-dwelling older people (≥65 years), alive in Stockholm County on 31 December 2015. We applied PIM criteria pertaining to the cardiovascular medication group (first-level ATC C group), and we assessed the association between PIM use and mortality and hospitalisation. RESULTS: Patients' (n = 315 120) mean age was 74.0 years (range 65-114), and 54.7% were women. There were 111 cardiovascular PIM criteria in the repository, from which 44 were not registered or prescribed in our population. We excluded another 43 requiring information not available in the database, or duplicates, resulting in 24 applicable criteria. The prevalence of polypharmacy (≥ five medications) was 25.5% and the prevalence of at least one PIM use was 8.3%, including 2.8% underuse and 5.3% misuse. Patients with intake of ≥10 medications had 38% increased mortality risk compared to those with 0-4 medications. Unplanned hospitalisation and emergency department visits were positively associated with underuse (12% and 25%, respectively) and misuse (13% and 12%, respectively). CONCLUSION: It was feasible to select a subset of cardiovascular PIM criteria originating from different PIM lists and to apply this subset in an administrative database. Additionally, by applying this subset, we showed significant associations with clinical outcome.

Initiation of advance care planning in newly admitted nursing home residents in Flanders, Belgium: A prospective cohort study.

AIM: To describe (i) the timing of initiation of advance care planning (ACP) after nursing home admission; (ii) the association of dementia and physical health with ACP initiation; and (iii) if and how analgesic use and use of lipid modifying agents is related to ACP, in a cohort of newly admitted residents. METHODS: A prospective, observational cohort study of nursing home residents was carried out. Data were collected 3 months, 15 months (year 1) and 27 months (year 2) after admission, using a structured questionnaire and validated measuring tools. RESULTS: ACP was never initiated during the 2-year stay for 38% of the residents, for 22% ACP was initiated at admission, for 21% during year 1 and for 19% during year 2 (n = 323). ACP initiation was strongly associated with dementia, but not with physical health. Residents without dementia were more likely to have ACP initiation at admission or not at all, whereas ACP initiation was postponed for residents with dementia. Between admission and year 2, analgesic use increased (from 34% to 42%), and the use of lipid-modifying agents decreased (from 28% to 21%). Analgesic use increased more in residents with ACP initiation during year 1 and year 2. The use of lipid-modifying agents was not associated with ACP. CONCLUSIONS: The timing of ACP initiation differed significantly for residents with and without dementia, which highlights the importance of an early onset of ACP before residents lose their decision-making capacity. ACP conversations might create opportunities to discuss adequate pain and other symptom treatment, and deprescribing at the end of life. Geriatr Gerontol Int 2019; 19: 141-146.

European repository of explicit criteria of potentially inappropriate medications in old age.

AIM: Lack of electronic assessment of medication lists in electronic health records is a barrier for more generalized use of potentially inappropriate medications (PIM) lists, designed for older adults. The aim was to construct a European repository of explicit criteria on PIM, suitable for electronic assessment. METHODS: PIM description, medication information, clinical information and level of evidence was entered. Criteria with unclear medication specifications were excluded. Too complex criteria were divided for more operable use. RESULTS: We selected three lists: the European Union (7)-PIM (2015), STOPP/START (2014) and Beers criteria (2015). After exclusion and division, from 641 original criteria of the three PIM-lists, a total of 650 criteria were entered (n = 282 from European Union (7)-PIM, n = 201 from Beers and n = 167 from the STOPP/START list). Identification of the medication was possible with the Anatomical Therapeutic Chemical Classification System for practically all criteria, except for 23 (3.5%). From all criteria, 63.9% required only medication-related information. In 55.7% of the criteria, identification of the active substance(s) was the only medication data requirement and 8.2% required additional information (dose, duration, route of administration). From all criteria, 36.1% required clinical information, from which 17.8% requested disease information only, and 18.3% required additional information (indication, history of diseases, laboratory results or severity of diseases). CONCLUSIONS: It was feasible to enter most of the original criteria of the three PIM lists into a repository of electronically applicable criteria. In the future, developers of new PIM lists should take into account semantic interoperability and consider the suitability of the criteria for electronic use. Geriatr Gerontol Int 2018; 18: 1293-1297.

Medication use in a cohort of newly admitted nursing home residents (Ageing@NH) in relation to evolving physical and mental health.

BACKGROUND: Medication use is high among nursing home (NH) residents, but there is a lack of longitudinal studies, determining medication use at admission and its evolution over time. AIM: Describing the evolution of the medication use two years after entering a NH, compared to the baseline observations and exploring the relation to the physical and mental health. METHODS: Data from the observational prospective Ageing@NH study, based on an inception cohort of newly admitted residents at NHs (65+) was used, selecting those consenting and with medication chart available. Information about socio-demographic, functional and mental characteristics, as well as medication use, was collected at baseline, year 1 and year 2. RESULTS: Medication chart was available for n = 741 at baseline (mean age 83.8, 66% female), and for n = 342 residents in year 2. The mean number of total medications increased from 8.9 to 10.1 (p-value < 0.001). Polypharmacy was high, with an increase in extreme polypharmacy from 23% to 32%. The biggest increase was noted in the respiratory (from 17% to 27%) and alimentary medications (from 80% to 87%). Cardiovascular medication use in year 2, was lower in those with stable high dependency (77%) and those evolving from low to high dependency (79%), than those with stable low dependency (89%) (p < 0.025). For residents with or evolving to dementia symptoms, decline in most medication groups was observed, especially in pain and sleeping medications, while antipsychotics use increased. CONCLUSION: Although medication use was high, signs of deprescribing were noted when the physical and mental health of the residents declined.

Influence of socioeconomic factors on hospital readmissions for heart failure and acute myocardial infarction in patients 65 years and older: evidence from a systematic review.

PURPOSE: Cardiovascular diseases are the leading cause of death and disability worldwide. Among these diseases, heart failure (HF) and acute myocardial infarction (AMI) are the most common causes of hospitalization. Therefore, readmission for HF and AMI is receiving increasing attention. Several socioeconomic factors could affect readmissions in this target group, and thus, a systematic review was conducted to identify the effect of socioeconomic factors on the risk for readmission in people aged 65 years and older with HF or AMI. METHODS: The search was carried out by querying an electronic database and hand searching. Studies with an association between the risk for readmission and at least one socioeconomic factor in patients aged 65 years or older who are affected by HF or AMI were included. A quality assessment was conducted independently by two reviewers. The agreement was quantified by Cohen's Kappa statistic. The outcomes of studies were categorized in the short-term and the long-term, according to the follow-up period of readmission. A positive association was reported if an increase in the risk for readmission among disadvantaged patients was found. A cumulative effect of socioeconomic factors was computed by considering the association for each study and the number of available studies. RESULTS: A total of eleven articles were included in the review. They were mainly published in the United States. All the articles analyzed patients who were hospitalized for HF, and four of them also analyzed patients with AMI. Seven studies (63.6%) were found for the short-term outcome, and four studies (36.4%) were found for the long-term outcome. For the short-term outcome, race/ethnicity and marital status showed a positive cumulative effect on the risk for readmission. Regarding the educational level of a patient, no effect was found. CONCLUSION: Among the socioeconomic factors, mainly race/ethnicity and marital status affect the risk for readmission in elderly people with HF or AMI. Multidisciplinary hospital-based quality initiatives, disease management, and care transition programs are a priority for health care systems to achieve better coordination.