Polypharmacy and multimorbidity
Effects of polypharmacy on main clinical outcomes.
Among 1332 elderly patients (aged 65 years or older) recruited in the REPOSI 2008, the prevalence of polypharmacy was 51.9% at hospital admission and 67.0% at discharge. Age, number of drugs at admission, hypertension, ischemic heart disease, heart failure, and chronic obstructive pulmonary disease were independently associated with polypharmacy at discharge. In multivariate analysis, the occurrence of at least one AE while in hospital was the only predictor of prolonged hospitalization (each new AE prolonged hospital stay by 3.57 days, p<0.0001). Age [odds ratio (OR) 1.04; 95% confidence interval (CI) 1.01-1.08; p=0.02), comorbidities (OR 1.18; 95% CI 1.12-1.24; p<0.0001), and AEs (OR 6.80; 95% CI 3.58-12.9; p<0.0001) were significantly associated with in-hospital mortality.
Eur J Clin Pharmacol. 2011 May;67(5):507-19. doi: 10.1007/s00228-010-0977-0. Epub 2011 Jan 11.
http://www.ncbi.nlm.nih.gov/pubmed/21221958
Appropriateness of drug prescribing
Proton pump inhibitors.
Among 1155 patients, 466 (40.3%) were treated with drugs for GERD or peptic ulcer were at hospital admission and 647 (56.0%) at discharge; 62.4% of patients receiving a drug for peptic ulcer or GERD at admission and 63.2% at discharge were inappropriately treated. Prevalence of inappropriate prescription of drugs for peptic ulcer or GERD remained almost the same at admission and discharge. Inappropriate use of these drugs is related to the concomitant use of other drugs.
Eur J Intern Med. 2011 Apr;22(2):205-10. doi: 10.1016/j.ejim.2010.11.009. Epub 2010 Dec 21.
http://www.ncbi.nlm.nih.gov/pubmed/21402255
Antidepressants
The number of patients treated with antidepressant medication at hospital admission was 115 (9.9%) and at discharge 119 (10.3%). In a multivariate analysis, a higher number of drugs (OR = 1.2; 95% CI = 1.1-1.3), use of anxiolytic drugs (OR = 2.1; 95% CI = 1.2-3.6 and OR = 3.8; 95% CI = 2.1-6.8), and a diagnosis of dementia (OR = 6.1; 95% CI = 3.1-11.8 and OR = 5.8; 95% CI = 3.3-10.3, respectively, at admission and discharge) were independently associated with antidepressant prescription. A specific diagnosis requiring the use of antidepressants was present only in 66 (57.4%) patients at admission and 76 (66.1%) at discharge.
Int Psychogeriatr. 2012 Apr;24(4):606-13. doi: 10.1017/S1041610211002353. Epub 2011 Dec 8.
http://www.ncbi.nlm.nih.gov/pubmed/22152153
Oral anticoagulants in atrial fibrillation
Among patients with atrial fibrillation, 26.5% at admission and 32.8% at discharge were not on antithrombotic therapy, and 43.7% at admission and 40.9% at discharge were not taking an appropriate therapy according to the CHADS2 score. Among elderly patients admitted with a diagnosis of atrial fibrillation to internal medicine wards, an appropriate antithrombotic prophylaxis was taken by less than 50%, with an underuse of vitamin K antagonist prescription independently of the level of cardio-embolic risk. Hospitalization did not improve the adherence to guidelines.
Eur J Intern Med. 2010 Dec;21(6):516-23. doi: 10.1016/j.ejim.2010.07.014. Epub 2010 Aug 15.
http://www.ncbi.nlm.nih.gov/pubmed/21111937
Effects of cardio-embolic and hemorrhagic scores on warfarin use
At admission, among 543 patients the median scores (range) were: CHADS2 2 (0-6), CHA2DS2-VASc 4 (1-9), HEMORR2HAGES 3 (0-7), HAS-BLED 2 (1-6). Most of the patients were at high cardio-embolic/high-intermediate bleeding risk (70.5% combining CHADS2 and HEMORR2HAGES, 98.3% combining CHA2DS2-VASc and HAS-BLED). 50-60% of patients were classified in a cardio-embolic risk category higher than the bleeding risk category. In univariate and multivariable analyses, a higher bleeding score was negatively associated with warfarin prescription, and positively associated with aspirin prescription. The cardio-embolic scores were associated with the therapeutic choice only after adjusting for bleeding score or age.
Eur J Intern Med. 2013 Dec;24(8):800-6. doi: 10.1016/j.ejim.2013.08.697. Epub 2013 Sep 12.
http://www.ncbi.nlm.nih.gov/pubmed/24035703
Association between thromboprophylaxis (TP) and venous thromboembolism (VTE), bleeding and death
Association between TP and VTE, bleeding and death in hospital and during the 3-month post-discharge follow-up were explored by logistic regression and propensity score analysis. Among the 1,380 patients enrolled, 171 (15.2 %) were on TP during the hospital stay (162 on low molecular weight heparins, 9 on fondaparinux). The disability Barthel index was the main independent predictor of TP prescription. Rate of fatal and non-fatal VTE and bleeding during and after hospitalization did not differ between TP and non-TP patients. In-hospital and post-discharge mortality was significantly higher in patients on TP, that however was not an independent predictor of mortality.
Among elderly medical patients there was a relatively low rate of TP, that was more frequently prescribed to patients with a higher degree of disability and who had an overall higher mortality.
Intern Emerg Med. 2013 Sep;8(6):509-20. doi: 10.1007/s11739-013-0944-8. Epub 2013 May 8.
http://www.ncbi.nlm.nih.gov/pubmed/23653407
Potentially inappropriate medications and risk of adverse clinical outcome
The prevalence of patients receiving at least one PIM was 20.1% and 23.5% according to the 2003 and 2012 versions of the Beers’ criteria, respectively. The 2012 Beers’ criteria identified more patients with at least one PIM than the 2003 version, although a high percentage of those patients (72.2%) were also identified by the criteria updated in 2003. The main difference in the prevalence of patients receiving a PIM according to the two versions of Beers’ criteria involved prescriptions of benzodiazepines for insomnia or agitation, chronic use of non-benzodiazepine hypnotics, prescription of antipsychotics in people with dementia and oral iron at dosage higher than 325 mg/day. Prescription of PIMs was not associated with a higher risk of adverse clinical events, re-hospitalization and all-cause mortality at 3-month follow-up in both univariate and multivariate analysis, after adjusting for age, sex and CIRS comorbidity index.
J Clin Pharm Ther. 2014 Oct;39(5):511-5. doi: 10.1111/jcpt.12178. Epub 2014 May 21.
http://www.ncbi.nlm.nih.gov/pubmed/24845066
Inappropriate prescription of allopurinol and febuxostat and risk of adverse events in the elderly: results from the REPOSI registry
Among the 4035 patients eligible for the analysis, 467 (11.6 %) were treated with allopurinol or febuxostat at hospital admission and 461 (13.2 %) among 3502 patients discharged. At admission, 39 (8.6 %) of patients receiving XO inhibitors and 43 (9.4 %) at discharge were appropriately treated. Among those inappropriately treated, hyperuricemia, polytherapy, chronic renal failure, diabetes, obesity, ischemic cardiomyopathy, heart failure, and cardiac dysrhythmias were associated with greater prescription of XO inhibitors. Prescription of XO inhibitors was associated with a higher risk of adverse clinical events in univariate and multivariate analysis. Prevalence of inappropriate prescription of XO inhibitors remained almost the same at admission and discharge. Inappropriate use of these drugs is principally related to treatment of asymptomatic hyperuricemia and various cardiovascular diseases.
Eur J Clin Pharmacol. 2014 Dec;70(12):1495-503. doi: 10.1007/s00228-014-1752-4.
http://www.ncbi.nlm.nih.gov/pubmed/25228251
The stigma of low opioid prescription in multimorbid elderly in Italy
The prevalence of opioid prescription was calculated at hospital admission and discharge. The prevalence of patients prescribed with opioids at admission was 3.8 % in the first run, 3.6 % in the second and 4.1 % in the third, whereas at discharge rates were slightly higher (5.8, 5.3, and 6.6 %). The most frequently prescribed agents were mild opioids such as codeine and tramadol. The number of total prescribed drugs was positively associated with opioid prescription in the three runs; in the third, dementia and a better functional status were inversely associated with opioid prescription. Finally, as many as 58 % of patients with significant pain at discharge were prescribed no analgesic at all. The conservative attitude of Italian physicians to prescribe opioids in elderly patients changed very little between hospital admission and discharge through a period of 5 years. Reasons for such a low opioid prescription should be sought in physicians’ and patients’ concerns and prejudices.
Intern Emerg Med. 2015 Apr;10(3):305-13. doi: 10.1007/s11739-014-1131-2.
http://www.ncbi.nlm.nih.gov/pubmed/25248643
Adherence to antibiotic treatment guidelines and outcomes in the hospitalized elderly with different types of pneumonia
The empirical antibiotic regimen was defined to be adherent to
guidelines if concordant with the treatment regimens recommended by
IDSA/ATS for CAP, HAP, and HCAP. A diagnosis of pneumonia was made in
317 patients. Only 38.8% of them received an empirical antibiotic
regimen that was adherent to guidelines. However, no significant
association was found between adherence to guidelines and outcomes.
Having HAP, older age, and higher CIRS severity index were the main
factors associated with in-hospital mortality.
Eur J Intern Med. 2015 Jun;26(5):330-7. doi: 10.1016/j.ejim.2015.04.002.
http://www.ncbi.nlm.nih.gov/pubmed/25898778
Prevalence and Risk Factors Associated with Use of QT-Prolonging Drugs in Hospitalized Older People
Among 3906 patients prescribed with at least one drug at admission, 2156 (55.2%) were taking at least one QT-prolonging drug. Risk factors independently associated with the use of any QT-prolonging drugs were found to be increasing age (OR 1.016 95%CI 1.01-1.026), multimorbidity (OR 2.69 95%CI 2.33-3.10), hypokalemia (OR 2.79 95%CI 1.32-5.89), atrial fibrillation (OR 1.664 95%CI 1.40-1.98), and heart failure (OR 3.17 95%CI 2.49-4.05). Furosemide, alone or in combination, was the most prescribed drug. Amiodarone was the most prescribed drug with a definite risk of TdP. Both the absolute number of QT-prolonging drugs (2890 vs 3549) and the number of patients treated with them (2456 vs 2156) increased at discharge. Among 1808 patients not prescribed QT-prolonging drugs at admission, 35.8% were prescribed with them at discharge. Despite their risk, QT-prolonging drugs are widely prescribed to hospitalized older persons in internal and geriatric wards.
Drugs Aging. 2016 Jan;33(1):53-61. doi: 10.1007/s40266-015-0337-y.
http://www.ncbi.nlm.nih.gov/pubmed/26693921
Drug-drug interactions
Drug interactions and adverse clinical events.
Among 2712 patients aged 65 years or older recruited at hospital admission in REPOSI 2008 and 2010, 1642 (60.5%) were exposed to at least one potential DDI and 512 (18.9%) to at least one potentially severe DDI. Among 2314 patients discharged, 1598 (69.1%) were exposed to at least one potential DDI and 1561 (24.2%) to at least one potentially severe DDI. Multivariate analysis found a significant association with an increased risk of mortality at 3 months in patients exposed to at least two potentially severe DDIs (Odds ratio 2.62; 95% confidence interval, 1.00–6.68; p = 0.05). Adverse clinical events were potentially related to severe DDIs in two patients who died in the hospital, in five readmitted, and one who died at 3 months after discharge.
Pharmacoepidemiol Drug Saf. 2013 Oct;22(10):1054-60. doi: 10.1002/pds.3510. Epub 2013 Aug 30.
http://www.ncbi.nlm.nih.gov/pubmed/24038765
Adherence to antithrombotic therapy guidelines improves mortality among elderly patients with atrial fibrillation.
Among 2535 patients, 558 (22.0 %) were discharged with a diagnosis of AF. Based on ESC guidelines, 40.9 % of patients were on guideline-adherent thromboprophylaxis, 6.8 % were overtreated, and 52.3 % were undertreated. Logistic analysis showed that increasing age (p = 0.01), heart failure (p = 0.04), coronary artery disease (p = 0.013), peripheral arterial disease (p = 0.03) and concomitant cancer (p = 0.003) were associated with non-adherence to guidelines. Undertreatment was significantly associated with increasing age (p = 0.001) and cancer (p < 0.001), and inversely associated with HF (p = 0.023). AF patients who were guideline adherent had a lower rate of both all-cause death (p = 0.007) and CV death (p = 0.024) compared to those non-adherent. Kaplan-Meier analysis showed that guideline-adherent patients had a lower cumulative risk for both all-cause (p = 0.002) and CV deaths (p = 0.011). On Cox regression analysis, guideline adherence was independently associated with a lower risk of all-cause and CV deaths (p = 0.019 and p = 0.006).
Clin Res Cardiol. 2016 May 31. [Epub ahead of print]
http://www.ncbi.nlm.nih.gov/pubmed/27245329
CLUSTER ANALYSIS
Effects on in-hospital mortality.
Patients affected by the clusters including heart failure (HF) and either chronic renal failure (CRF), or chronic obstructive pulmonary disease had a significant association with in-hospital death (OR=4.2;95%CI=1.6-11.4; OR=2.9;95%CI=1.1-8.1, respectively), as well as patients affected by CRF and anaemia (OR=6.0;95%CI=2.3-16.2). The cluster including HF and CRF was also associated with adverse clinical events (OR=3.5;95%CI=1.5-7.7). The effect of both HF and CRF and CRF and anaemia on in-hospital death was additive.
Rejuvenation Res. 2010 Aug;13(4):469-77. doi: 10.1089/rej.2009.1002.
http://www.ncbi.nlm.nih.gov/pubmed/20586646
Comparison of clusters of 2008 and 2010.
Data from the REPOSI Registry were used to evaluate and compare patterns of diseases identified with cluster analysis in two samples of hospitalized elderly during 2008 (1,411 subjects enrolled in 38 hospitals wards) and 2010 (1,380 subjects in 66 wards). To analyze patterns of multimorbidity, a cluster analysis was performed including the same diseases (19 chronic conditions with a prevalence >5%) collected at hospital discharge during the two years of the registry. Eight clusters of diseases were identified in 2008 and six in 2010. Several diseases were included in similar clusters in the two years, such as malignancy and liver cirrhosis; anemia, gastric and intestinal diseases; diabetes and coronary heart disease; chronic obstructive pulmonary disease and prostate hypertrophy.
Gerontology. 2013;59(4):307-15. doi: 10.1159/000346353. Epub 2013 Jan 25.
http://www.ncbi.nlm.nih.gov/pubmed/23364029
Cluster analysis and drug utilization
Association between clusters of diseases and polypharmacy.
Among clusters of diseases, the highest mean number of drugs (N=8) was found in patients affected by heart failure (HF) plus chronic obstructive pulmonary disease (COPD), HF plus chronic renal failure (CRF), COPD plus coronary heart disease (CHD), diabetes mellitus plus CRF, and diabetes mellitus plus CHD plus cerebrovascular disease (CVD). The strongest association between clusters of diseases and polypharmacy was found for diabetes mellitus plus CHD plus CVD, diabetes plus CHD, and HF plus atrial fibrillation (AF).
Eur J Intern Med. 2011 Dec;22(6):597-602. doi: 10.1016/j.ejim.2011.08.029. Epub 2011 Sep 29.
http://www.ncbi.nlm.nih.gov/pubmed/22075287
RE-HOSPITALIZATION
Predictors of re-hospitalization.
Nineteen percent of patients were re-admitted at least once within 3 month after discharge. Multivariate logistic regression analysis showed that only AEs during hospitalization, previous hospital admission, and vascular and liver diseases were significantly associated with likelihood of readmission.
Eur J Intern Med. 2013 Jan;24(1):45-51. doi: 10.1016/j.ejim.2012.10.005. Epub 2012 Nov 8.
http://www.ncbi.nlm.nih.gov/pubmed/23142413
COGNITIVE IMPAIRMENT
Cognitive impairment and clinical outcomes.
Elderly patients with cognitive impairment were more likely to die during hospitalization with a severity-dependent association. Adverse events may represent an important target of prevention due to their high association with mortality and cognitive impairment.
J Gerontol A Biol Sci Med Sci. 2013 Apr;68(4):419-25. doi: 10.1093/gerona/gls181. Epub 2012 Sep 12.
http://www.ncbi.nlm.nih.gov/pubmed/22972941
Anticholinergic properties of drugs and cognitive performance.
Drugs with anticholinergic properties identified by the ACB scale and ARS are associated with worse cognitive and functional performance in elderly patients. The ACB scale might permit a rapid identification of drugs potentially associated with cognitive impairment in a dose-response pattern, but the ARS is better at rating activities of daily living.
Drugs Aging. 2013 Feb;30(2):103-12. doi: 10.1007/s40266-012-0044-x.
http://www.ncbi.nlm.nih.gov/pubmed/23239364
Under-detection of delirium and impact of neurocognitive deficits on in-hospital mortality.
Delirium was coded in 2.9%, while deficits in attention, orientation, and memory were found in 35.4%, 29.7% and 77.5% of patients. Inattention and either disorientation or memory deficits were found in 14.1%, while combination of the 3 deficits in 19.8%. Delirium, as per ICD-9 codes, was not a predictor of in-hospital mortality. In contrast, objective deficits of inattention, in combination with orientation and memory disorders, were stronger predictors after adjusting for covariates. The documentation of delirium is poor in medical wards of Italian acute hospitals. Neurocognitive deficits on objective testing (in a pattern suggestive of undiagnosed delirium) should be used to raise awareness of delirium, given their association with in-hospital mortality.
Eur J Intern Med. 2015 Aug 31. pii: S0953-6205(15)00253-8. doi: 10.1016/j.ejim.2015.08.006
http://www.ncbi.nlm.nih.gov/pubmed/26333532
PROGNOSTIC MEASURE
eGFR and clinical outcomes.
In a sample of elderly patients (n = 1,363) eGFR was calculated at hospital admission and at discharge by the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. Subjects were classified into three groups: 1 normal eGFR (≥60 ml/min/1.73 m2, reference group), 2 moderately reduced eGFR (30-59 ml/min/1.73 m2) and 3 severely reduced eGFR (<30 ml/min/1.73 m2). Patients with the lowest eGFR on admission were more likely to be older, to have a greater cognitive and functional impairment and a high rate of comorbidities. Multivariable logistic regression analysis showed that severely reduced eGFR at the time of admission was associated with in-hospital mortality (OR 3.00; 95 % CI 1.20-7.39, p = 0.0230), but not with re-hospitalization (OR 0.97; 95 % CI 0.54-1.76, p = 0.9156) or mortality at 3 months after discharge (OR 1.93; 95 % CI 0.92-4.04, p = 0.1582). On the contrary, an increased risk (OR 2.60; 95 % CI 1.13-5.98, p = 0.0813) to die within 3 months after discharge was associated with decreased eGFR measured at the time of discharge.
Intern Emerg Med. 2013 Dec 14. [Epub ahead of print].
http://www.ncbi.nlm.nih.gov/pubmed/24338497
Heart failure and chronic kidney disease in a registry of internal medicine wards.
Of the 1380 patients enrolled, 27.9% had HF (age 80 + 7, BMI 27 + 6 kg/m2) and 17.4% CKD (age 81 + 7, BMI 26.8 + 6 kg/m2). Both groups were significantly older (P < 0.0001) with BMI higher than the patients without those diagnosis (P < 0.02). Patients with a history of CKD showed higher non-fasting glycaemia (140 + 86 vs. 125 + 63 mg/dL, P < 0.001). CKD was significantly associated with HF (P < 0.0001). Patients with HF had an estimated GFR lower than patients without HF (P < 0.0001). Comorbidity and severity indices were significantly higher in subjects with HF (P < 0.0001) and CKD (P < 0.0001) than in those without. Multivariable analysis showed a significant association between HF and age (for five years increase OR 1.13, P < 0.009), BMI (for each 3 kg/m2 increase OR 1.15, P < 0.001), GFR (for each decrease of 10 mL/min increase OR 0.92, P < 0.002) and severity index (SI) (for each 0.25 units increase OR 1.43, P < 0.001. HF on admission is strongly associated with CKD, older age, BMI, and SI.
European Geriatric Medicine 2014; 5: 307-13. doi:10.1016/j.eurger.2014.08.005
http://www.sciencedirect.com/science/article/pii/S1878764914001740
Gout, allopurinol intake and clinical outcomes in the hospitalized multimorbid elderly.
Increased serum uric acid has been considered a cardiovascular risk factor but no study has assessed its relation with hospital mortality or length of stay. The prevalence of gout/hyperuricemia and its association with clinical parameters was evaluated in the REPOSI Registry. Of 1380 patients, 139 (10%) had a diagnosis of gout or were prescribed allopurinol. They had more co-morbidities (7.0 vs 5.6; P<0.0001) and consumed more drugs (6.8 vs 5.0; P<0.0001). The CIRS (co-morbidity index) was worse in these patients (OR 1.28 95% CI 1.15-1.41). Multivariable regression analysis showed that only renal and heart failures were independently associated with gout/allopurinol intake. Moreover, this combined event was associated with an increased risk of adverse events during hospitalization (OR 1.66, 95% CI 1.16-2.36), but not with the risk of re-hospitalization, length of hospital stay or death.
Eur J Intern Med. 2014 Nov;25(9):847-52. doi: 10.1016/j.ejim.2014.09.019.
http://www.ncbi.nlm.nih.gov/pubmed/25439099
Brain and kidney, victims of atrial microembolism in elderly hospitalized patients?
It is well known that atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with a higher risk of stroke, and new evidence links AF to cognitive impairment, independently from an overt stroke (CI). Our aim was to investigate, assuming an underlying role of atrial microembolism, the impact of CI and CKD in elderly hospitalized patients with AF. Among the 1384 patients enrolled, 321 had AF. Patients with AF were older, had worse CI and disability and higher rates of stroke, hypertension, heart failure, and CKD, and less than 50% were on anticoagulant therapy. Among patients with AF, those with worse CI and those with lower estimated glomerular filtration rate (eGFR) had a higher mortality risk (odds ratio 1.13, p=0.006). Higher disability levels, older age, higher systolic blood pressure, and higher eGFR were related to lower probability of oral anticoagulant prescription. Lower mortality rates were found in patients on oral anticoagulant therapy.
Eur J Intern Med. 2015 Mar 4. pii: S0953-6205(15)00053-9. doi: 10.1016/j.ejim.2015.02.018.
http://www.ncbi.nlm.nih.gov/pubmed/25749554
Predictors of clinical events occurring during hospital stay among elderly patients admitted to medical wards in Italy.
During the hospital stay 427 patients (33.7%) experienced at least one ICE and 19 of them died as a consequence of an ICE. The most common ICEs were urinary tract infections, pneumonia, anaemia, arrhythmia and fluid electrolyte disorders. Independent predictors of any ICE were being a bladder catheter holder (RR [risk ratio] 1.86, 95% CI 1.52 – 2.27), being on treatment at home with a proton-pump inhibitor (RR 1.25, 95% CI 1.03 – 1.53) or an immunosuppressant therapy (RR 2.10, 95% CI 1.24 – 3.56), after correction for age, sex, comorbidity, cognitive impairment, functional dependence. Three clinical characteristics, easy to be assessed at admission, can be useful to identify older inpatients at a higher risk for ICEs during hospital stay.
Eur J Intern Med. 2016 Jul;32:38-42. doi: 10.1016/j.ejim.2016.04.003. Epub 2016 May 4.
http://www.ncbi.nlm.nih.gov/pubmed/27157402
GENDER DIFFERENCES
Gender-differences in disease distribution and outcome in hospitalized elderly: data from the REPOSI Study.
Women live longer and outnumber men. On the other hand, older women develop more chronic diseases and conditions such as arthritis, osteoporosis and depression, leading to a greater number of years of living with disabilities. Aim of this study was to describe whether or not there are gender differences in the demographic profile, disease distribution and outcome in a population of hospitalized elderly people.
Eur J Intern Med. 2014 Sep;25(7):617-23. doi: 10.1016/j.ejim.2014.06.027. Epub 2014 Jul 19.
http://www.ncbi.nlm.nih.gov/pubmed/25051903
Gender difference in drug use in hospitalized elderly patients.
Polypharmacy (>5 drugs) was more frequent in men both at hospital admission and discharge. At hospital discharge, the number of prescriptions increased in both sexes at all age groups. Neuropsychiatric drugs were significantly more prescribed in women (p<0.0001). At admission men were more likely to be on antiplatelets (41.7% vs 36.7%; p=0.0029), ACE-inhibitors (28.7% vs 24.7%; p=0.0072) and statins (22.9% vs 18.3%; p=0.0008). At discharge, antiplatelets (43.7% vs 37.3%; p=0.0003) and statins (25,2% vs 19.6%; p<0.0001) continued to be prescribed more often in men, while women were given beta-blockers more often than men (21.8% vs 18.9%; p=0.0340). Proton pump inhibitors were the most prescribed drugs regardless of gender. At discharge, the medication pattern did not change according to gender.
Eur J Intern Med. 2015 Jul 22. pii: S0953-6205(15)00232-0. doi: 10.1016/j.ejim.2015.07.006.
http://www.ncbi.nlm.nih.gov/pubmed/26209883
Clinical severity, age, and sex overcome cardiometabolic morbidities but not stroke as predictors of mortality in elderly inpatients.
Data from 2,703 individuals were analyze: logistic analysis indicated that diabetes mellitus, IHD, and stroke were not independent predictors of in-hospital and or 3-month mortality. Only stroke had an independent association with mortality at 1- year follow-up. Age, sex, and severity index were strong predictors of mortality, excluding male sex, which was not associated with in-hospital mortality.
J Am Geriatr Soc. 2016 Aug;64(8):1737-9. doi: 10.1111/jgs.14197. Epub 2016 Jul 26.
http://www.ncbi.nlm.nih.gov/pubmed/27458820
2013 REPOSI International Seminar
Aging, multimorbidity and polypharmacy: which strategies for the Third Millennium
The goals and challenge of this International Seminar are to promote more effective and focused clinical and research approaches to multimorbidity in the oldest old, taking into account different European healthcare scenarios, experiences and expertises.
In the European Union (EU) the number of people aged >75 years is projected to double by the year 2060, comprising 20% of the total population. These changes will lead to an increase of 20 to 40% of the costs necessary to maintain the existing quality of healthcare services. Multimorbidity is almost constant in the oldest old and has such adverse consequences as higher mortality, poorer quality of life and functional status. Elderly people with multimorbidity are usually treated with multiple medications, and polypharmacy leads to drug interactions, adverse reactions, poor compliance, heightened health service use, inadequate coordination of care and higher treatment burden.
Current therapeutic guidelines are based upon randomized clinical trials, that enroll only highly selected, relatively young patients suffering from a single disease. This population is obviously very different from the oldest old and very few of the available guidelines take into due account multimorbidity and overall medication burden.
This background highlights the need of making drug prescription more appropriate and personalized, also ensuring that decision making takes into account patients’ life expectancy, concerns and priorities.
There is also a need to bolster a patient-centered approach instead of the current disease-focused efforts, that inevitably lead to fragmentation of healthcare of the elderly and inappropriate use of facilities.