‘Deprescribing’ Can Reduce Harm of Medications in Elderly

MedicalResearch.com Interview with:
“Pills” by Victor is licensed under CC BY 2.0Khalid Ali, MBBS, FRCP, MD

Senior lecturer in Geriatrics
Brighton and Sussex Medical School, UK 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Older people are more like to have more than one chronic condition (multi-morbidity), and as such as are more likely to be prescribed several medications (poly pharmacy) to treat those conditions. At the point of hospital discharge, older people are given different / new medications in addition to their old ones, and this puts them at higher risk of harm related to medicines. Our study led by  Brighton and Sussex Medical School (BSMS) and King’s College London involved five hospitals and 1,280 patients (average age 82 years) in South England. Senior pharmacists interviewed patients and carers, reviewed GP records and analysed hospital readmission to determine medication-related harm.

The study found that more than one in three patients (37%) experienced harm from their medicines within two months of hospital discharge, and that this was potentially preventable in half of the cases. Medication-related harm was most commonly found to occur from the toxicity of the medicine itself and in a quarter of cases from poor adherence.  The medicines found to pose the highest risk were opiates, antibiotics and benzodiazepines. Patients suffered a range of side effects including serious kidney injury, psychological disturbance, irregular heart rhythms, confusion, dizziness, falls, diarrhoea, constipation and bleeding.

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How To Prevent the Elderly From Falling?

MedicalResearch.com Interview with:

Dr. Alex Krist

Dr. Krist

Dr. Alex Krist, M.D., M.P.H.

Dr. Krist is is a professor of family medicine and population health at Virginia Commonwealth University and active clinician and teacher at the Fairfax Family Practice residency.

What is the background for these recommendation statements? What are the main findings?

Response: Falls are the leading cause of injuries in adults age 65 and older and can lead to serious disability and even death. Bone fractures—which may result from a fall—can also cause serious disability and death in older adults.

The U.S. Preventive Services Task Force looked into the most recent evidence on the best ways to prevent falls and fractures in older adults. We found that clinicians should recommend exercise or physical therapy to help prevent falls by older adults who live at home and are at higher risk for falling.

Additionally, we concluded that taking a low dose of vitamin D and calcium does not help prevent fractures due to osteoporosis, but we don’t know if taking a higher dose is effective or not, so we are calling for more research.

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More Hip Fractures in Elderly on Antidepressants

MedicalResearch.com Interview with:

Sanna Torvinen-Kiiskinen MSc (Pharm.), PhD student, Kuopio Research Centre of Geriatric Care and School of Pharmacy University of Eastern Finland

Sanna Torvinen-Kiiskinen

Sanna Torvinen-Kiiskinen
MSc (Pharm.), PhD student,
Kuopio Research Centre of Geriatric Care and School of Pharmacy
University of Eastern Finland

MedicalResearch.com: What is the background for this study?

Response: Antidepressants are widely used among elderly persons, especially persons with Alzheimer’s disease. They are used not only for treatment for major depression, but for treatment of anxiety, insomnia and chronic pain as well as behavioral symptoms caused by dementia.

However, antidepressants, as well as other psychotropic drugs, may cause sedation, confusion, orthostatic hypotension and hyponatremia, which increase the risk of falling and fractures. Because of changes in pharmacodynamics and pharmacokinetics due to aging, older persons are at the higher risk of those adverse events.

The aim of our study was to investigate whether antidepressant use is associated with an increased risk of hip fracture among community-dwelling persons with and without Alzheimer’s disease.

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Strict Systolic Blood Pressure Control Might Impact Cognition In Elderly

MedicalResearch.com Interview with:
Dr. Enrico Mossello

Research Unit of Medicine of Ageing
Department of Experimental and Clinical Medicine
University of Florence

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Mossello: In spite of the high prevalence of high blood pressure (HBP) and cognitive impairment in old age, their relationship is still controversial. While several (but not all) studies have identified high blood pressure as a risk factor for incident cognitive impairment, evidence regarding the prognostic role of blood pressure in cognitively impaired older subjects is scarce and inconsistent. To our knowledge, no longitudinal study has been published up to now regarding Ambulatory Blood Pressure Monitoring (ABPM) in subjects with cognitive impairment. Moreover recent European and American guidelines on HBP leave decisions on antihypertensive therapy of frail elderly patients to the treating physician and do not provide treatment targets for cognitively impaired patients.

In the present cohort study of subjects with dementia and Mild Cognitive Impairment (MCI) low values of day-time systolic blood pressure measured with ABPM were associated with greater progression of cognitive decline after a median 9-month follow-up. This association was limited to subjects treated with anti-hypertensive drugs and was independent of age, vascular comorbidity and baseline cognitive level, holding significant both in dementia and in Mild Cognitive Impairment subgroups. A similar trend of association was observed for office systolic blood pressure, although this was weaker and did not reach statistical significance in all analyses.

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Yoga May Improve Cognitive Health in Older Adults

Neha P. Gothe, PhD Division of Kinesiology Health and Sport Studies Wayne State University Detroit, MI 48202.Medical Research Interview with:
Neha P. Gothe, PhD
Division of Kinesiology, Health and Sport Studies
Wayne State University
Detroit, MI 48202.

Medical Research: What are the main findings of the study?

Dr. Gothe: The yoga group was speedier and more accurate on tests of information recall, mental flexibility and task-switching than it had been before the intervention. Participants in the yoga group showed significant improvements in working memory capacity, which involves continually updating and manipulating information. They were also able to perform the task at hand quickly and accurately, without getting distracted.
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Falls May Be Increased By High Doses of Blood Pressure Medications in Elderly

Dr. Michele Callisaya Faculty of Medicine, Nursing & Health Sciences Monash University, ClaytonMedicalResearch.com Interview with: 
Dr. Michele Callisaya
Faculty of Medicine, Nursing & Health Sciences
Monash University, Clayton

MedicalResearch: What are the main findings of the study?

Dr. Callisaya: Falls are common in older people and can lead to hip fracture and loss of mobility.  Blood pressure reducing medications are commonly taken by older people to protect against heart attacks and stroke, but may have some unwanted side effects such as light-headedness and loss of balance.  We found that older people who were on large doses of such medications were at increased risk of falling.

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Hearing Loss Contributes to Personality Changes in Elderly

Dr. Anne Ingeborg Berg: University of Gothenburg, SwedenMedicalResearch.com Interview with:
Dr. Anne Ingeborg Berg:
University of Gothenburg, Sweden
MedicalResearch.com: What are the main findings of the study?

Answer: In our study of personality change in individuals aged 80+ we found that over a 6 year period individuals did not change in emotional stability, however, in line with previous research they got less extravert or outgoing. The only health aspect that could be related to an accelerated change in extraversion was impaired hearing at the first measurement occasion.

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Falling-Related Deaths in Elderly Increased by Cardiovascular Diseases, Medications

Judy A. Stevens PhD National Center for Injury Prevention and Control Centers for Disease Control and Prevention Atlanta GA 30341MedicalResearch.com Interview with:
Judy A. Stevens PhD
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention Atlanta
GA 30341


MedicalResearch.com: What are the main findings of the study?

Dr. Stevens: The fall death rate among persons aged 65 and older has been increasing rapidly. We used vital statistics data to examine the circumstances and contributing conditions to fall deaths.

We found that of 21,649 fall deaths in 2010, the largest proportion (35%) occurred from falling on the same level, followed by falling on stairs or steps (6.5%).  From 1999 to 2010, there was a trend toward more specific reporting of falls circumstances. However, information about the circumstances of 49% of the 2010 fall deaths was not available.

In 2010, 49% of fall deaths involved a head injury and 30% involved a hip fracture. The most important contributing causes to fall deaths were circulatory diseases, especially hypertension, and respiratory diseases.

Factors that may partially explain the rapid increase in the fall death rate include changing trends in the death rates for underlying chronic diseases strongly associated with falls, such as reductions in cardiovascular disease deaths, as well as better reporting on death certificates of falls as the underlying cause of death.

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Diabetes Mellitus: New Onset in Elderly – What is Optimal HbA1c Level?

MedicalResearch.com Interview with: Dr. Orit Twito

Department of Endocrinology, Hillel Yaffe Medical Center, Hadera, Israel

MedicalResearch.com: What are the main findings of the study?

Answer: An HbA1c level above 7.5% (58mmol/mol) is associated with increased risk for all-cause mortality and with a lower revascularization rate in elderly patient with new onset diabetes mellitus. HbA1c above 8.5 %( 69nmol/mol) was associated with even higher mortality rate, although this difference did not reach statistical significance. Continue reading

Diabetes in the Elderly: Indivualized Treatment with Vildagliptin (Glavus)

MedicalResearch.com Interview with: Dr David Strain, MRCP MD

Clinical senior lecturer and honorary consultant
University of Exeter Medical School
Institute of Biomedical and Clinical Science
Department of Diabetes and Vascular Research
Royal Devon & Exeter Hospital Exeter EX2 5AX

MedicalResearch.com: What is the Background of the study?

In early 2010 recent diabetes outcome trials such as ACCORD and ADVANCE had put into question the benefit of aggressive HbA1c reduction for all patients particularly in elderly population. After that there were several guidelines that suggested individualizing treatment targets for elderly patients according to their age, co-morbidities, frailty and baseline HbA1c. This featured in the Finnish guidelines and the European Working Party for the management of Diabetes in the Older Person. However this was also completely without any evidence base. I worked with Paivi Paldanius (the final author of the paper and a medical advisor for Novartis) to establish a pragmatic study. We both acknowledged the importance of having a patient-centric, pragmatic and ‘real-life’ approach and as there was already evidence that DPP-4 inhibitors, in this case vildagliptin (due to Päivi’s affiliation), had demonstrated it’s efficacious and had no tolerability issues in the elderly population we decided to go ahead with the study.

It was obvious that we needed to implement a holistic approach and take into account as many clinically relevant parameters as possible, such as age, baseline HbA1c, duration of the disease, co-morbidities and frailty, for implementation of the individualized care. Our primary goal was to request that the physicians acting as investigators would still apply their clinical judgment based on these clinical features of each individual patient but also, follow their local guidelines as in their daily clinical practice. This would later provide us with invaluable information and perspective when interpreting the data and recommending implementation of the results.  For assessment of frailty we screened for many different methodologies but Prof Timo Strandberg (known expert of the field and mentioned in the acknowledgements section of our paper) suggested to apply modified Linda Fried’s method for assessment of phenotype of frailty as this method is validated, very pragmatic, reproducible and also feasible to be used for the first time also by a non-geriatric investigator. All investigators were trained to follow these parameters by the protocol. We also wished to evaluate in parallel the conventional HbA1c drop assessment in order to be able to put the potential success of our new endpoint, meeting the individualized target, into perspective and for comparison against other standard data from other studies with DPP-4 inhibitors with elderly. We also wished to simulate a clinical, real-world setting as much as possible and included patients who would seem representative of most elderly T2DM patients.
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