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》
Sex Differences in Characteristics Associated with Potentially Inappropriate Medication Use and Associations with Functional Capacity in Older Participants of the Berlin Aging Study II.
Medication safety is a vital aim in older adults' pharmacotherapy. Increased morbidity and vulnerability require particularly careful prescribing. Beneath avoiding unnecessary polypharmacy and prescribing omissions, physicians have to be aware of potentially inappropriate medications (PIMs) and related outcomes to optimize older adults' drug therapy, and to reduce adverse drug events.
The aim of this study was to identify participants characteristics associated with PIM use and associations of PIM use with functional capacity with a focus on sex differences.
Multivariable logistic regression analyses of cross-sectional Berlin Aging Study II (BASE-II) data (N = 1,382, median age 69 years, interquartile range 67-71, 51.3% women) were performed with PIM classification according to the EU(7)-PIM list.
In the overall study population, higher education was associated with lower odds of PIM use (odds ratio [OR] 0.93, confidence interval [CI] 95% 0.87-0.99, p = 0.017). Falls (OR 1.53, CI 95% 1.08-2.17, p = 0.016), frailty/prefrailty (OR 1.68, 1.17-2.41, p = 0.005), and depression (OR 2.12, CI 95% 1.32-3.41, p = 0.002) were associated with increased odds of PIM use. A better nutritional status was associated with lower odds of PIM use (OR 0.88, CI 95% 0.81-0.97, p = 0.008). In the sex-stratified analysis, higher education was associated with lower odds of PIM use in men (OR 0.90, CI 95% 0.82-0.99, p = 0.032). Frailty/prefrailty was associated with increased odds of PIM use in men (OR 2.04, CI 95% 1.18-3.54, p = 0.011) and a better nutritional status was associated with lower odds of PIM use in men (OR 0.83, CI 95% 0.72-0.96, p = 0.011). Falls in the past 12 months were related to an increased prevalence of PIM use in women (OR 1.74, CI 95% 1.10-2.75, p = 0.019). Depression was associated with a higher prevalence of PIM use in both men (OR 2.74, CI 95% 1.20-6.24, p = 0.016) and women (OR 2.06, CI 95% 1.14-3.71, p = 0.017). We did not detect sex differences regarding the overall use of drugs with anticholinergic effects, but more men than women used PIMs referring to the cardiovascular system (p = 0.036), while more women than men used PIMs referring to the genitourinary system and sex hormones (p < 0.001).
We found similarities, but also differences between men and women as to the associations between PIM use and participants' characteristics and functional capacity assessments. The association of lower education with PIM use may suggest that physicians' prescribing behavior is modified by patient education, a relationship that could evolve from more critical attitudes of educated patients towards medication use. We conclude that sex differences in associations of PIM use with functional capacities might be partly attributable to sex differences in drug classes used, but not with regard to anticholinergics, as these are used to a similar extent in men and women in the cohort studied here.
Toepfer S
，König M
，Spira D
，Drewelies J
，Kreutz R
，Bolbrinker J
，Demuth I
... -
《-》
Utilization and Spending on Potentially Inappropriate Medications by US Older Adults with Multiple Chronic Conditions using Multiple Medications.
The utilization of potentially inappropriate medications (PIMs) in older adults can lead to adverse events and increased healthcare costs. Polypharmacy, the concurrent utilization of multiple medications, is common in older adults with multiple chronic conditions.
To investigate the utilization and costs of PIMs in multimorbid older adults with polypharmacy over time.
This retrospective cross-sectional study used linked Medicare claims and electronic health records from seven hospitals/medical centers in Massachusetts (2007-2014). Participants were ≥65 years old, had ≥2 chronic conditions (to define multimorbidity), and used drugs from ≥5 pharmaceutical classes for ≥90 days (to define polypharmacy). Chronic conditions were defined using the Chronic Conditions Indicator from the Agency for Health Research and Quality. PIMs were defined using the American Geriatrics Society 2019 version of the Beers criteria. We calculated the percentage of patients with ≥1 PIMs and the percentages of patients using different types of PIMs. We used logistic regression analyses to test the odds of taking ≥1 PIMs. We calculated mean costs spent on PIMs by dividing the costs spent on PIMs by the total medication cost.
≥69% of patients used ≥1 PIM. After adjusting for healthcare utilization, chronic conditions, medication intake, and demographic factors, female sex (2014: Odds ratio (OR)=1.27, 95%CI 1.25-1.30), age (2014: OR=0.92, 95%CI 0.90-0.93), and Hispanic ethnicity (2014: OR=1.41, 95%CI 1.27-1.56) were associated with PIM use. Gastrointestinal drugs and central nervous system drugs were the most commonly-used PIMs. In patients using ≥1 PIM, >10% of medication costs were spent on PIMs.
The utilization of PIMs in US older adults with multimorbidity and polypharmacy is high.
Jungo KT
，Streit S
，Lauffenburger JC
《-》
ResearchGate
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