Drugs & Aging最新文献

This is the executive summary of a work by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) (Nicholas Fuggle et al. in Drugs, 2024).

Background: Central nervous system (CNS)-active polypharmacy (defined as concurrent exposure to three or more antidepressant, antipsychotic, antiseizure, benzodiazepine, opioid, or nonbenzodiazepine benzodiazepine receptor agonists) is associated with significant potential harms in persons living with dementia (PLWD).We conducted a pilot trial to assess a patient nudge intervention's implementation feasibility and preliminary effectiveness to prompt deprescribing conversations between PLWD experiencing CNS-active polypharmacy and their primary care clinicians ("clinicians").

Methods: We used the electronic health record to identify PLWD prescribed CNS-active polypharmacy in primary care clinics from two health systems. Clinics were assigned to intervention (n = 10) or control (n = 12), with PLWD in intervention clinics mailed an educational brochure to prompt discussion with clinicians about the appropriateness of their CNS-active regimen. We conducted chart reviews for evidence of documentation related to these medications and used the electronic health record (EHR) to assess preliminary effectiveness 120 days after sending the brochure (e.g., number of CNS-active medications prescribed, change in total standardized daily dose [TSDD] of CNS-active medications, and change in prevalence of CNS-active polypharmacy). We interviewed 10 clinicians from intervention clinics to assess their perceptions about the acceptability of the intervention.

Results: PLWD in the intervention group (n = 61) and control group (n = 68) had an average age of 72.4 years (standard deviation [SD] 9.7), 62.8% were female, and 84.5% were white. We did not find any documented evidence of conversations related to CNS-active medications between PLWD who received the brochure and their primary care clinicians. After 120 days, there was no significant between-group difference in the mean number of CNS-active medications prescribed (- 1.0 [SD 1.3] versus - 1.0 [SD 1.3]), mean TSDD (- 1.6 [SD 6.0] versus - 1.3 [SD 5.8]), or the percentage of patients with CNS-active polypharmacy (52.6% versus 50.4%). Interviews with clinicians suggested they were aware that combinations of CNS-active medications were not ideal; however, they reported inheriting patients who were already on these medications, and they did not have sufficient clinic time or access to safer alternatives to overcome patient hesitation to deprescribe.

Conclusions: A direct-to-patient mailed educational brochure did not demonstrate feasibility in provoking deprescribing conversations between PLWD and clinicians or preliminary effectiveness in decreasing CNS-active polypharmacy.

Background: Inpatient anticholinergic medications have been associated with a higher likelihood of postoperative delirium in older adults. However, it remains unclear whether administering anticholinergic medications after surgery adversely affects long-term cognitive function.

Objective: We aimed to evaluate the relationship between in-hospital anticholinergic medications and time to incident dementia in a cohort of older surgical patients. We also sought to determine whether the association between in-hospital anticholinergic drugs and dementia differed by sex and prehospital anticholinergic exposure.

Methods: This was a retrospective analysis of electronic health record data from a regional health information exchange. The study population included patients aged 50 years and older who underwent major surgery requiring an inpatient stay between 2014 and 2021. Orders for anticholinergic medications were identified using the anticholinergic cognitive burden (ACB) scale. A Cox proportional hazards model was used to estimate the association between inpatient orders for strong anticholinergics and incident dementia after hospital discharge. Cause-specific hazards were modeled. Stratification and relative excess risk due to interaction (RERI) were used to investigate multiplicative and additive interaction, respectively.

Results: In total, 66,420 surgical encounters were analyzed. Approximately 90% of patients received one or more strong anticholinergics during hospitalization, and 3806 patients developed dementia during a median follow-up of 3.4 years. The median time to dementia was 2.2 years. Each one-order increase in inpatient anticholinergic medications was associated with a 0.60% increase in dementia risk (HR 1.006; 95% CI 1.003-1.008). This association was stronger among patients who were prescribed anticholinergics before hospitalization (RERI 0.10; 95% CI 0.08-1.12; p = 0.0122).

Conclusions: Perioperative anticholinergics may increase the risk of dementia after major surgery. Avoiding these medications in hospitalized older adults may improve long-term cognitive outcomes.

Background: Recent guidelines recommend the use of sodium-glucose cotransporter 2 (SGLT-2) inhibitors (SGLT2i) in patients suffering from cardiorenal diseases. However, the safety and efficacy of SGLT2i in older adults with atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease (CKD) remain unclear.

Methods: Online databases were queried from inception to 11 July 2023 to identify primary or secondary analyses for inclusion. Efficacy outcomes included all-cause mortality, cardiovascular (CV) death, hospitalization for heart failure (HHF), major adverse cardiac events (MACE), CV death/HHF composite, and cardiorenal composite events. Safety endpoints included acute kidney injury (AKI), serious adverse events, genital infections, limb amputation, fractures, urinary tract infections (UTI), and volume depletion. Data were pooled using a random-effects model to derive risk ratios (RRs) and 95% confidence intervals (CIs).

Results: Eight trials with 32,541 older adults identified in primary or secondary analyses were included. In older adults, SGLT2i reduced the risk of all-cause mortality (RR 0.88; 95% CI 0.83- 0.95), CV death (RR 0.82; 95% CI 0.74-0.92), HHF (RR 0.72; 95% CI 0.66-0.79), MACE (RR 0.87; 95% CI 0.77-0.99), CV death/HHF composite (RR 0.78; 95% CI 0.70-0.88), and cardiorenal composite events (RR 0.77; 95% CI 0.70-0.85). For safety endpoints, SGLT2i decreased the risk of serious adverse events (RR 0.92; 95% CI 0.89-0.95) and increased the risk of genital infections (RR 3.48; 95% CI 2.58-4.69).

Conclusions: This analysis of randomized trials demonstrates that SGLT2i are efficacious in older adults. However, since older individuals are often underrepresented in most clinical trials, further research targeting this growing demographic is essential.

Chronic itch in older patients is a common problem, with a significant impact on quality of life. Chronic itch in the older population may be attributable to several causes, such as age-related changes, skin conditions, systemic conditions, medications, and psychological conditions. Given the complexity of itch in this population, comorbidities, and polypharmacy in most geriatric patients, treating chronic itch can be challenging for healthcare providers. Therefore, optimized topical treatment regimens are paramount to help these patients and prevent side effects.

Introduction: Chronic pain is prevalent among older adults with Alzheimer's disease (AD) and Alzheimer's disease-related dementias (ADRD). Memantine and acetylcholinesterase inhibitors (ACHEI; donepezil, rivastigmine, and galantamine) are approved for the treatment of dementia symptoms and may also have analgesic properties. However, findings on the clinical utility of these dementia medications for chronic pain treatment are mixed, and little is known about differences in the use of pain medication according to whether an older adult with AD/ADRD is using dementia medications.

Methods: We selected a 20% national sample of Medicare enrollees with a diagnosis of AD/ADRD and chronic pain in 2020. We calculated the odds of having any pain management prescription (opioids, serotonin and norepinephrine reuptake, gapapentinoids, or non-steroidal anti-inflammatory drugs), having an opioid prescription, and having a long-term (≥ 90 days) opioid prescription, by dementia medication (none, memantine, ACHEI, or memantine and ACHEI).

Results: Among 103,564 patients, 5.5% received a memantine prescription, 14.4% received an ACHEI prescription, and 8.6% received a prescription for both. Over 70% of all patients had a pain management prescription. The percentage of patients who had an opioid prescription ranged from 54.5% for those without a dementia medication prescription to 44.0% for those with a prescription for both memantine and ACHEI. Similarly, the percentage of patients who had a long-term opioid prescription was highest for those without a dementia medication prescription (12.2%) and lowest for those with a prescription for both memantine and ACHEI (8.8%). Having a prescription for memantine only was associated with lower odds of any pain management prescription (odds ratio [OR]: 0.94; 95% confidence interval [CI]: 0.88-1.00; p < 0.05). Having a prescription for either memantine (OR: 0.79; 95% CI 0.75-0.84), ACHEI (OR: 0.85; 95% CI 0.82-0.89), or both (OR: 0.75; 95% CI 0.72-0.79) was associated with lower odds of having an opioid prescription (p < 0.05). Lastly, having a prescription for either memantine (OR: 0.85; 95% CI 0.77-0.94), ACHEI (OR: 0.92; 95% CI 0.86-0.98), or both (OR: 0.83; 95% CI 0.77-0.90) was associated with lower odds of having a long-term opioid prescription.

Discussion: Older adults with co-occurring AD/ADRD and chronic pain who were on dementia medications had lower odds of being prescribed opioid analgesics. Memantine and ACHEIs should be explored as potential opioid-sparing medications for older adults with AD/ADRD, given their relatively safe profiles. Future studies are needed to examine repurposing dementia medications for pain treatment.

Osteoarthritis (OA) is a chronic condition in which pain significantly affects quality of life, often leading to reduced physical activity and disability. Globally, an estimated 595 million people are affected, with the numbers likely to increase owing to an aging population and rising obesity rates. Effective pain management is crucial, yet current treatments, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, often provide limited relief and come with risks. One reason for this limited success is the insufficient recognition of the importance of psychosocial factors and heterogeneity of patients with OA (such as anxiety and depression), which can exacerbate pain and its impacts. The variability in patient pain experiences highlights the potential value of pain phenotyping, which involves a comprehensive assessment of pain characteristics to tailor treatments to individual needs. Antidepressants, particularly serotonin-norepinephrine reuptake inhibitors (SNRIs), show promise in alleviating both psychological symptoms and OA-related pain, but their effectiveness varies among individuals. Therefore, further research into standardized pain phenotyping methods and their integration into antidepressant treatment is needed to improve efficacy and minimize side effects through more personalized approaches.

Introduction: Older adults represent a growing proportion of the general population. Nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a group of medicines that are both necessary, owing to their anti-inflammatory, analgesic, and cardioprotective abilities, and potentially harmful, owing to their side effects.

Objectives: This study provides a comprehensive analysis of NSAID usage patterns among Polish adults aged 60 years and older. It focused on the regular use (≥ three times per week) of two types of NSAIDs: acetylsalicylic acid (ASA) and non-ASA NSAIDs, examining consumption on the basis of age, sex, educational level, and place of residence.

Methods: Data were collected from the PolSenior2 study, a national cross-sectional survey of 5987 Polish individuals aged 60-106 years, conducted from 2018 to 2019.

Results: The study found that 30.7% [95% confidence interval (CI) 28.8-32.7)]of Polish seniors regularly used NSAIDs, with 26.2% (95% CI 24.5-28.0) regularly using ASA, 6.3% (95% CI 5.3-7.2) regularly using non-ASA NSAIDs, and 1.9% (95% CI 1.4-2.3) reporting regular use of both. An age-related increase in regular NSAID use, including ASA, was observed. Women were more likely than men to use non-ASA NSAIDs regularly, whereas men in the 70-79 age group were more likely to use ASA. A lower level of education was associated with more frequent NSAID use.

Conclusions: The findings have implications for healthcare practitioners and policymakers, emphasizing the need for careful management of NSAID use. The study contributes to a more nuanced understanding of NSAID usage and underscores the necessity for tailored healthcare strategies to ensure safe and effective medication use among older adults.

Introduction: Polypharmacy is increasing among older individuals worldwide. Deprescribing has been suggested as a strategy to reduce polypharmacy, but it has had a limited impact.

Objective: This study investigated the facilitators and barriers to deprescribing in older adults, as perceived by primary care general practitioners, focusing particularly on factors influencing deprescribing in frail individuals.

Methods: A qualitative approach was employed and semistructured interviews were conducted between 9 April and 29 May 2024 with a sample of 30 general practitioners working in primary care facilities in Crete, Greece. The interviews were recorded and transcribed verbatim. Thematic analysis was performed on the basis of the Theoretical Domains Framework.

Results: Several barriers to deprescribing were revealed, including a lack of expertise and motivation, inadequate communication skills, time constraints, and negative beliefs toward deprescribing held by physicians and patients. The lack of an established role for general practitioners in primary care, the absence of a national initiative targeting polypharmacy, and the influence of pharmacists and pharmaceutical representatives were highlighted as challenges. The identified facilitators included the incorporation of deprescribing recommendations and considerations for frail patients into guidelines, fostering a strong doctor-patient relationship, promoting shared decision-making, facilitating effective collaboration with caregivers, and utilizing nonpharmacological therapy.

Conclusions: General practitioners encounter both barriers and facilitators when making deprescribing decisions for older adults, particularly those with frailty syndrome. Researchers and policymakers can use the findings of this research to guide future interventions and promote successful deprescribing practices.

Cancer-related cognitive impairment significantly affects cancer management and decision-making. While the exact mechanisms underlying cancer-related cognitive dysfunction remain complex and multifaceted, different factors have been identified that may help predict which patients are at increased risk for cognitive decline. In this article, we provide a comprehensive overview of systemic cancer therapy-induced cognitive impairment in older adults, including signs and symptoms, diagnosis, and management. In addition, we discuss the evidence available on the impact of endocrine therapy, cytotoxic chemotherapy, immunotherapy and targeted agents on cognition in this population.