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.

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.

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.

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.

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.

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.