Frailty and Potentially Inappropriate Medication Use at Nursing Home Transition.

To estimate the prevalence of potentially inappropriate medication (PIM) use among older adults with cognitive impairment or dementia prior to and following admission to nursing homes and in relation to frailty. Retrospective cohort study using health administrative databases. Ontario, Canada. 41,351 individuals with cognitive impairment or dementia, aged 66+ years newly admitted to nursing home between 2011 and 2014. PIMs were defined with 2015 Beers Criteria and included antipsychotics, H2 -receptor antagonists, benzodiazepines, and drugs with strong anticholinergic properties. Medication information was obtained at nursing home admission and in the subsequent 180 days. Multivariable Cox proportional-hazards models were used to assess the impact of frailty status (determined by a 72-item frailty index) on the hazard of starting and discontinuing PIMs. At admission, 44% of residents with cognitive impairment or dementia were on a PIM and prevalence varied by frailty (38.7% non-frail, 42.8% pre-frail, and 48.1% frail, P < .001). Following admission, many residents discontinued PIMs (23.5% for antipsychotics, 49.3% benzodiazepines, 32.2% anticholinergics, and 30.9% H2 -receptor antagonists). However, PIMs were also introduced with 10.9% newly started on antipsychotics, benzodiazepines (10.1%), anticholinergics (6.6%), and H2 -receptor antagonists (1.2%). After adjustment for other characteristics, frail residents had a similar risk of PIM discontinuation as non-frail residents except for anticholinergics (HR = 1.21, 95% CI 1.06-1.39) but were more likely to be newly prescribed benzodiazepines (HR = 1.32, 95% CI 1.20-1.44), antipsychotics (HR = 1.36, 1.23-1.49), and anticholinergics (HR = 1.34, 95% CI 1.20-1.50). Many residents with cognitive impairment or dementia enter nursing homes on PIMs. PIMs are more likely to be started in frail individuals following admission. Interventions to support deprescribing of PIMs should be implemented targeting frail individuals during the transition to nursing home.

Maclagan LC ，Maxwell CJ ，Gandhi S ，Guan J ，Bell CM ，Hogan DB ，Daneman N ，Gill SS ，Morris AM ，Jeffs L ，Campitelli MA ，Seitz DP ，Bronskill SE ... -  《-》

Sex Differences in Antipsychotic and Benzodiazepine Prescribing Patterns: A Cohort Study of Newly Admitted Nursing Home Residents with Dementia in Ontario, Canada.

Maclagan LC ，Maxwell CJ ，Harris DA ，Campitelli MA ，Diong C ，Lapane KL ，Hogan DB ，Rochon P ，Herrmann N ，Bronskill SE ... -  《-》

How do potentially inappropriate medications and polypharmacy affect mortality in frail and non-frail cognitively impaired older adults? A cohort study.

To test whether the use of potentially inappropriate central nervous system acting medications, proton pump inhibitors (PPIs) or polypharmacy are associated with mortality in cognitively impaired older adults and whether frailer people are at greater risk of harm. A cohort study nested within the Cognitive Function and Ageing Study II, a population representative cohort study of the older population in Cambridgeshire, Nottingham and Newcastle, UK. A total of 1154 cognitively impaired participants, aged 65 years or older. Any use of antipsychotics, antidepressants, other anticholinergic medication, benzodiazepines or PPIs, polypharmacy (5-9) and hyperpolypharmacy (≥10 reported medications) were ascertained at baseline. Frailty was assessed using the Fried criteria. Mortality up to 8 years follow-up. HRs associated with potentially inappropriate medication (PIM), frailty and their interaction were estimated adjusting for covariates. Within the sample, 44% were taking one or more PIM. Apart from antipsychotics (adjusted HR=3.24, 95% CI 1.83 to 5.73), use of specific PIM was not associated with greater subsequent mortality. Polypharmacy (HR=1.17, 95% CI 0.95 to 1.45) and hyperpolypharmacy were associated with mortality (HR=1.60, 95% CI 1.16 to 2.22). Being frail (HR=1.90, 95% CI 1.32 to 2.72) or prefrail (HR=1.56, 95% CI 1.10 to 2.20) was associated with increased mortality. There was some evidence that the HR for polypharmacy on mortality was lower among frailer individuals, but the overall polypharmacy by frailty interaction was not statistically significant (p=0.102). For those with cognitive impairment, greater concern should be afforded to the number of medications than the prescription of specific classes. Frailer individuals may have a lower relative risk of mortality associated with polypharmacy than less frail individuals.

Porter B ，Arthur A ，Savva GM 《BMJ Open》

Polypharmacy, potentially inappropriate medication and cognitive status in Austrian nursing home residents: results from the OSiA study.

Alzner R ，Bauer U ，Pitzer S ，Schreier MM ，Osterbrink J ，Iglseder B ... -  《-》

Predictors of Cholinesterase Discontinuation during the First Year after Nursing Home Admission.

For persons with dementia, the appropriate duration of cholinesterase inhibitor (ChEI) use remains unclear. We examined patterns of ChEI use during nursing home (NH) transition and the factors associated with discontinuation following admission. Population-based retrospective cohort study using linked health administrative and Resident Assessment Instrument Minimum Dataset, version 2.0 databases. A total of 47,851 older adults (mean age = 84.8 years, standard deviation = 6.8) with dementia newly admitted to a NH in Ontario, Canada between 2011 and 2015. ChEI use at admission and during the following year was identified from prescription claims. Resident sociodemographic and health characteristics at admission, including a 72-item frailty index, were derived from the Resident Assessment Instrument Minimum Dataset 2.0. Additional resident and prescriber characteristics were derived from administrative data. Discontinuation was defined as a 30+-day gap in ChEI supply. Multivariable subdistribution hazard models were used to estimate the independent effect of resident frailty and other factors on ChEI discontinuation. Approximately one-third (17,560) of residents with dementia were on a ChEI at admission. Among this group, 17.7% (3110) discontinued use over follow-up. Incidence of discontinuation was significantly higher among residents with syncope [subdistribution hazard ratio, sHR = 2.21, 95% confidence interval, CI (1.52, 3.22)], more severe behavioral symptoms [sHR = 1.79, 95% CI (1.57, 2.05)], cognitive impairment [sHR = 1.26, 95% CI (1.07, 1.48)], higher frailty, [sHR = 1.19, 95% CI (1.04, 1.36)], and a primary prescriber active in the NH [sHR = 1.28, 95% CI (1.14, 1.45)]. A significantly lower incidence was observed for older and unmarried residents and those with a longer duration of use. Less than one-fifth of residents on a ChEI at admission discontinued use during the following year. Although some of the predictors of discontinuation align with past research and current clinical recommendations, others were unexpected and point to novel drivers of ChEI use. Future investigations should explore the varied reasons underlying these associations and resident outcomes associated with ChEI discontinuation.

Maclagan LC ，Bronskill SE ，Guan J ，Campitelli MA ，Herrmann N ，Lapane KL ，Hogan DB ，Amuah JE ，Seitz DP ，Gill SS ，Maxwell CJ ... -  《-》