Journal of the American Medical Directors Association最新文献

Objectives: To assess recent trends in antipsychotic use among older adults with Alzheimer's disease and related dementias (ADRDs) according to their residential status and determine the factors associated with the use of antipsychotics.

Design: Population-based, cross-sectional study using Texas Medicare Fee-for-Service data.

Setting and participants: Individuals ≥ 65 years of age with ADRDs who had at least 3 months of Medicare Part A and B, and Part D for prescription drug coverage, in any year between 2015 and 2020.

Methods: Temporal trends for antipsychotic use were reported by calendar year, and the associations between antipsychotic use and potential predictors were assessed overall and by residential status.

Results: Among an annual average of 161,848 older adults with ADRDs (median age, 82 years; 64.8% female), overall antipsychotic use decreased by 25.8%, from 14.5% in 2015 to 10.8% in 2020. The decline was primarily observed among those with any nursing facility (NF) residence, where use dropped from 22.1% to 12.4%, whereas community-dwelling individuals maintained a steady rate of approximately 10%. Factors associated with increased antipsychotic use included male sex, Black and Hispanic individuals, dual eligibility, Alzheimer's disease, emergency department visits, hospitalization, depression, and anxiety disorders. However, these associations varied across residential statuses. Older age was more strongly associated with decreased antipsychotic use among those with NF residence than those in the community. Compared with White individuals, Black individuals were more likely to receive antipsychotics in the community, whereas Hispanic and Asian individuals were more likely to receive antipsychotics among those with NF residence.

Conclusions and implications: Although antipsychotic use substantially decreased among those with NF residence, it remained steady among community-dwelling individuals. Given that two-thirds of individuals with dementia reside in the community, more attention is needed to understand antipsychotic use in this population.

Objectives: We aimed to examine changes in the incidence of injurious falls before, during, and after stroke, and to identify risk factors of injurious falls before and after stroke diagnosis.

Design: Prospective cohort study.

Setting and participants: Within the Swedish Twin Registry, 4431 participants (aged 66.5 ± 10.3 years) with incident stroke and 4431 stroke-free controls (aged 66.5 ± 10.3 years) were identified and matched with cases according to birth year and sex. Cases and controls were retrospectively and prospectively followed for a total of 21 years.

Methods: Information on the onset of stroke and injurious falls was ascertained from medical records in the National Patient Registry. Data were analyzed using conditional Poisson regression and generalized estimating equation models.

Results: During the 4- to 10-year pre-stroke period, the standardized incidence rates of injurious falls were 4.29-7.53 per 1000 person-years in stroke and 3.97-7.47 per 1000 person-years in control groups. The incidence of injurious falls among participants with stroke was significantly higher compared with non-stroke controls beginning 3 years before stroke (incidence rate ratio [IRR], 1.27; 95% confidence interval [CI], 1.02-1.59), peaked during the year of stroke diagnosis (IRR, 2.55; 95% CI, 2.17-3.01), and declined 4 years after stroke (IRR, 1.42; 95% CI, 1.14-1.77) until reaching a similar level as the controls (IRRs around 1.11-1.56). Former/current smoking, heavy drinking, and overweight were associated with increased falls during the pre-stroke period, and being single and heart disease with falls during the post-stroke period.

Conclusions and implications: Among people with stroke, incidence of injurious falls is significantly elevated already 3 years before stroke diagnosis and lasting until 4 years post-stroke. Risk factors for falls differ pre-stroke and post-stroke. Taking preventive measures may be beneficial in managing both stroke and fall-related risks.

Objectives: Gastrointestinal bleeding, an emergency and critical disease, is affected by multiple factors. This study aims to systematically summarize and appraise various factors associated with gastrointestinal bleeding.

Design: Umbrella review.

Setting and participants: Meta-analyses that evaluated environmental and clinical factors concerning gastrointestinal bleeding.

Methods: We conducted a systematic search to identify eligible meta-analyses. For each included study, the risk estimates, heterogeneity estimates, small-study effects, excess significance tests, and publication biases were recalculated and appraised. Furthermore, we considered the methodologic quality and classified the evidence.

Results: In this study, 51 beneficial and 44 harmful associations were found. This study found that preemptive transjugular intrahepatic portosystemic shunt was the most reliable treatment to reduce gastroesophageal variceal bleeding and mortality risk, followed by antibiotics. For gastroduodenal ulcer bleeding, Yunnan Baiyao and proton pump inhibitors (PPIs) were relatively dependable treatment drugs, and the comparatively reliable prophylactic drugs comprised PPIs and H₂-receptor antagonists. Patients with hemodynamic instability and larger ulcers had a higher risk of rebleeding. Both weekend admissions and the combination of selective serotonin reuptake inhibitors and nonsteroidal anti-inflammatory drugs were high-risk factors for upper gastrointestinal bleeding and mortality. We also found that tranexamic acid was a credible drug for overall gastrointestinal bleeding. Meanwhile, aspirin, warfarin, diabetes, and renal failure were all high-risk factors.

Conclusions and implications: Altogether, many factors can substantially influence gastrointestinal bleeding. Therefore, in daily life and clinical practice, we should not only remain cautious in prescribing and taking some drugs but also pay attention to the management of lifestyle and underlying diseases. If necessary, protective drugs should be properly supplemented.