Annika Kragh

Older Adults' Medication Use 6 Months Before and After Hip Fracture: A Population-Based Cohort Study

OBJECTIVES: To study changes in use of fall‐risk increasing drugs (FRIDs) and bone density–related medication in participants with hip fracture before and after the fracture and to analyze differences between five healthcare districts.

In-hospital medication reviews reduce unidentified drug-related problems

PurposeTo examine the impact of a new model of care, in which a clinical pharmacist conducts structured medication reviews and a multi-professional team collates systematic medication care plans, on the number of unidentified DRPs in a hospital setting.MethodsIn a prospective two-period study, patients admitted to an internal medicine ward at the University Hospital of Lund, Sweden, were included if they were ≥ 65 years old, used ≥ 3 medications on a regular basis and had stayed on the ward for ≥ 5 weekdays. Intervention patients were given the new model of care and control patients received conventional care. DRPs were then retrospectively identified after study completion from blinded patient records for both intervention and control patients. Two pairs of evaluators independently evaluated and classified these DRPs as having been identified/unidentified during the hospital stay and according to type and clinical significance. The primary endpoint was the number of unidentified DRPs, and the secondary endpoints were the numbers of unidentified DRPs within each type and clinical significance category.ResultsThe study included a total of 141 (70 intervention and 71 control) patients. The intervention group benefited from a reduction in the total number of unidentified DRPs per patient during the hospital stay: intervention group median 1 (1st–3rd quartile 0–2), control group 9 (6–13.5) (p < 0.001), and also in the number of medications associated with unidentified DRPs per patient: intervention group 1 (0–2), control group 8 (5–10) (p < 0.001). All sub-categories of DRPs that were frequent in the control group were significantly reduced in the intervention group. Similarly, the DRPs were less clinically significant in the intervention group.ConclusionsA multi-professional team, including a clinical pharmacist, conducting structured medication reviews and collating systematic medication care plans proved very effective in reducing the number of unidentified DRPs for elderly in-patients.

Drug-related problems in the elderly

Drug-related problems in the elderly is intended to serve as a source of information and clinical support in geriatric pharmacotherapy for students as well as all health care professionals, e.g. physicians, nurses and pharmacists. Pharmacotherapy is of great importance to all mankind. Drugs are however powerful and must be handled appropriately. This is especially important for elderly patients. Drug-related problem is not a major subject in most university programmes in medicine or pharmacy. When there is no specific course, there is often no book covering the topic. In our view, as teachers at various university courses, there has been a shortage of literature that re ects the most important aspects of drug-related problems in the elderly. Medical practitioners, nurses and pharmacists, need to have this knowledge to be able to serve their patients in the best way. This book covers most aspects of drug-related problems in the elderly. With b- ter knowledge of drug-related dif culties and risks we hope that elderly will have fewer drug-related problems and bene t more from their pharmacotherapy. (Less)

Bleeding and first-year mortality following hip fracture surgery and preoperative use of low-dose acetylsalicylic acid: an observational cohort study

BackgroundHip fracture is associated with high mortality. Cardiovascular disease and other comorbidities requiring long-term anticoagulant medication are common in these mostly elderly patients. The objective of our observational cohort study of patients undergoing surgery for hip fracture was to study the association between preoperative use of low-dose acetylsalicylic acid (LdAA) and intraoperative blood loss, blood transfusion and first-year all-cause mortality.MethodsAn observational cohort study was conducted on patients with hip fracture (cervical requiring hemiarthroplasty or pertrochanteric or subtrochanteric requiring internal fixation) participating in a randomized trial that found lack of efficacy of a compression bandage in reducing postoperative bleeding. The participants were 255 patients (≥50 years) of whom 118 (46%) were using LdAA (defined as ≤320 mg daily) preoperatively. Bleeding variables in patients with and without LdAA treatment at time of fracture were measured and blood transfusions given were compared using logistic regression. The association between first-year mortality and preoperative use of LdAA was analyzed with Cox regression adjusting for age, sex, type of fracture, baseline renal dysfunction and baseline cardiovascular and/or cerebrovascular disease.ResultsBlood transfusions were given postoperatively to 74 (62.7%) LdAA-treated and 76 (54%) non-treated patients; the adjusted odds ratio was 1.8 (95% CI 1.04 to 3.3). First-year mortality was significantly higher in LdAA-treated patients; the adjusted hazard ratio (HR) was 2.35 (95% CI 1.23 to 4.49). The mortality was also higher with baseline cardiovascular and/or cerebrovascular disease, adjusted HR 2.78 (95% CI 1.31 to 5.88). Patients treated with LdAA preoperatively were significantly more likely to suffer thromboembolic events (5.7% vs. 0.7%, P = 0.03).ConclusionsIn patients with hip fracture (cervical treated with hemiarthroplasty or pertrochanteric or subtrochanteric treated with internal fixation) preoperative use of low-dose acetylsalicylic acid was associated with significantly increased need for postoperative blood transfusions and significantly higher all-cause mortality during one year after surgery.

Inappropriate Drugs in the Elderly

Use of inappropriate drugs is common among elderly. These drugs are associated with an increased risk of adverse drug reactions in older adults. Here we focus on four groups of drugs that are frequently used by older patients but should, if possible, be avoided. These groups are: benzodiazepines, antipsychotic drugs, drugs with anticholinergic effects, and non-steroidal anti-inflammatory drugs (NSAID). Benzodiazepines, anticholinergic drugs and antipsychotic drugs may cause delirium, especially in the elderly. Possible severe adverse effects from NSAIDs are e.g. gastrointestinal bleeding, renal, and heart failure. Elderly patients are more susceptible to adverse drug reactions from all these drugs due to pharmacokinetical and pharmacodynamical alterations. In most cases there are safer alternatives.

Compliance and Concordance

On average 50% of patients are compliant to long term medication treatment. Non-compliance is a drug-related problem as it may result in negative outcomes for the patient. Non-compliance can be intentional or non-intentional and related to knowledge, attitudes, and also practical problems including memory and administration difficulties. The decision to take a medication or not (compliance) lay in the hand of the patient, but the health care providers can support the patient in this decision with the aim to improve the patients’ health. Definitions and tools to detect negative patient and health-care behaviour and methods for concordance are presented in this chapter.

Physiological Alterations with Aging

Elderly are more susceptible to adverse drug reactions than younger persons. This is partly due to age-related physiological changes that affect pharmacodynamics and pharmacokinetics. An understanding of these age-related changes and of the pharmacokinetics of individual drugs is important before prescribing drugs to elderly patients. The most frequent and important change affecting pharmacokinetics is the decline in renal elimination. A disability to excrete drugs is an important consequence of the impaired kidney function that occurs in old age and it increases the risk of drug-accumulation and adverse drug reactions. Pharmacodynamical changes affect most organs since the older patients have impaired homeostatic mechanisms.

Practical Problems Related to the Patients Medication Intake

Why do patients refer to medications as the little white pill or the pink capsule? Strange or confusing names are problematic especially if you are old and have many medications. Other potential practical medication problems in the elderly including problems to remember, to swallow, practical handling, food- and drug- interactions, short use-before date are listed and described in this chapter. Possible solutions are also presented. For patient safety and for cost-effective care it’s very important to identify and solve these problems for the individual patient. A systematic model for this is presented in Chapter 10.

Aging and Drugs

The number of elderly is increasing in the developed part of the world. With increasing age the prevalence of many diseases will increase. This promotes high use of drugs. Pharmacotherapy can effectively cure, prevent or alleviate many conditions and improve quality of life but with aging there is an increased risk of drug-related problems. Older people are often excluded in trials, hence we often have limited knowledge regarding efficacy of pharmacotherapy in the elderly. Polypharmacy is common among elderly, which complicates pharmacotherapy since the risks of drug-drug interactions and adverse drug effects are increased.

Summary and Perspectives

The health care system can help elderly people to stay healthy or to improve health if a systematic process to patient care can be provided. The first step is to look upon all new medication treatment as an experiment, and therefore continuously follow-up on the patient objectives of the treatment, documenting treatment goals and results, and communicating this with the patient and all involved health care-professionals.