Drugs & Aging最新文献

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.

Background: Atopic dermatitis (AD) is a chronic inflammatory skin condition that can be particularly challenging to manage in older adults. Dupilumab, a monoclonal antibody targeting the interleukin-4 receptor alpha subunit, has shown promise in treating moderate to severe AD. However, its efficacy and safety in older adults with refractory AD have not been extensively studied.

Objective: The objective of this study is to evaluate the efficacy and safety of dupilumab in treating older adults with refractory atopic dermatitis and to determine its potential as a therapeutic option in this demographic.

Methods: A retrospective, single-center study was conducted involving 73 older adults (aged ≥ 60 years) with moderate-to-severe AD. The Eczema Area and Severity Index (EASI), Pruritus Numerical Rating Scales (P-NRS), and Dermatology Life Quality Index (DLQI) scores were recorded at baseline and at weeks 6 and 16. Adverse events (AEs) were also monitored.

Results: Following dupilumab treatment, a significant reduction in EASI, P-NRS, and DLQI scores was observed compared with baseline (p < 0.0001), indicating improved clinical symptoms and quality of life. Adverse events were mostly mild and did not lead to treatment discontinuation.

Conclusions: Dupilumab demonstrates significant efficacy and a favorable safety profile in managing refractory AD in older adults, suggesting it as a potential effective therapeutic option for this demographic.

Objective: The use of anticoagulants to prevent deep vein thrombosis (DVT) after intracerebral hemorrhage (ICH) remains controversial. This study aims to evaluate the safety of anticoagulants in preventing DVT in patients with ICH.

Methods: Data were sourced from the Chinese Stroke Center Alliance. The primary outcomes include in-hospital mortality, intracranial hematoma evacuation, and hematoma expansion. Absolute standardized differences (ASD) are used to assess differences between groups, and multivariate logistic regression analysis is employed to analyze correlations. Platelet counts and international normalized ratio (INR) were examined within subgroups. Propensity score matching (PSM) is used for sensitivity analysis.

Results: A total of 56,633 patients with ICH were finally enrolled. Multivariate logistic regression analysis revealed that anticoagulant use correlated with reduced in-hospital mortality and hematoma expansion (OR: 0.59, 95% CI: 0.50-0.69, p < 0.001 and OR: 0.55, 95% CI: 0.41-0.73, p < 0.001), while no association was observed with intracranial hematoma evacuation clearance (OR: 1.00, 95% CI: 0.93-1.08, p = 0.941). Subgroup analysis revealed an increased risk of intracranial hematoma evacuation with anticoagulant use when INR >1.7 (OR: 1.47, 95% CI: 1.15-1.89, p = 0.002), but not of in-hospital mortality (OR: 1.20, 95% CI: 0.78-1.85, p = 0.409) or hematoma expansion (OR: 0.66, 95% CI: 0.19-2.25, p = 0.503). PSM yielded consistent outcomes.

Conclusions: Post-ICH anticoagulant therapy to prevent DVT is safe, posing no heightened risk of in-hospital mortality, intracranial hematoma evacuation, or hematoma expansion. However, caution is warranted in patients with coagulopathies.

Introduction: In older adults, trazodone is frequently prescribed for anxiety and insomnia owing to its perceived greater tolerability in comparison with benzodiazepines. However, it may have hypotensive effects.

Aim: The aim of this study is to investigate the effects of trazodone on orthostatic blood pressure (BP) response and risk of syncope and falls in hypertensive older adults.

Patients and methods: A longitudinal observational study involving patients ≥ 75 years was conducted in two geriatric outpatient clinics in Florence, Italy. At baseline, participants underwent a 3-min active stand test, office BP measurement and home and ambulatory BP monitoring. At follow-up, syncope and falls were recorded.

Results: Among 123 participants (mean age 81 years, 59% female), 12 (10%) reported regular trazodone use. Trazodone users showed lower office diastolic BP (71.8 versus 80.1 mmHg, p = 0.042), a greater systolic and diastolic BP reduction immediately after standing (Δsystolic_T0 23.8 versus 14.3 mmHg, p = 0.037; Δdiastolic_T0 8.9 versus 1.6 mmHg, p = 0.004) and a greater diastolic BP reduction after 1-min standing (Δdiastolic_T1 6.5 versus 0 mmHg, p = 0.029). No differences were reported for home or ambulatory BP. Incidence of syncope and falls was 25%, with a significantly higher rate in patients receiving trazodone (58.3% versus 21.2%, p = 0.001). Trazodone use predicted syncope and falls independently of age, disability and fall history. This association was not confirmed when adjusting for dementia diagnosis. BP values were not associated with the study outcome.

Conclusions: In older hypertensive outpatients, trazodone is associated with a greater orthostatic BP drop and may predispose them to an increased risk of syncope and falls.

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.

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: 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.