Beatrice Gasperini

Potentially inappropriate drug prescriptions and risk of hospitalization among older, Italian, nursing home residents: the ULISSE project

AbstractBackground Potentially inappropriate medications in older patients increase the risk of adverse drug events, which are an important cause of hospital admission and death among hospitalized patients. Little information is available about the prevalence of potentially inappropriate drug prescriptions (PIDPs) and the related health adverse outcomes among nursing home (NH) residents. Objective To estimate the prevalence of PIDPs and the association with adverse outcomes in NH residents. Methods A total of 1716 long-term residents aged ≥65 years participating in the ULISSE (Un Link Informatico sui Servizi Sanitari Esistenti per l’anziano [A Computerized Network on Health Care Services for Older People]) project were evaluated using a standardized comprehensive geriatric assessment instrument, i.e. the inter Resident Assessment Instrument Minimum Data Set. A thorough evaluation of residents’ drug use, medical diagnoses and healthcare resource utilization was performed. A PIDP was defined according to the most recent update of the Beers criteria. Results Almost one out of two persons (48%) had at least one PIDP and almost one out of five had two or more PIDPs (18%). Residents with a higher number of PIDPs had a higher likelihood of being hospitalized. Compared with residents without PIDPs, those with two or more PIDPs at baseline had a higher probability of being hospitalized (hazard ratio 1.73; 95% CI 1.14, 2.60) during the following 12 months. Risk of PIDP was positively associated with the total number of drugs and diseases, but negatively with age. PIDPs defined according to specific conditions (n = 780; 55%) were slightly more frequent than PIDPs based on single medications irrespective of specific indication (n=639; 45%). Conclusions PIDP is a significant problem among Italian NH residents. There is an urgent need for intervention trials to test strategies to reduce inappropriate drug use and its associated adverse health outcomes.

Predictors of hospitalization in Italian nursing home residents: the U.L.I.S.S.E. project.

OBJECTIVE To examine resident and facility characteristics associated with hospitalization in a cohort of Italian older nursing home residents. DESIGN A longitudinal observational study. SETTING The nursing homes participating in the U.L.I.S.S.E. study, a project evaluating the quality of care for older persons in Italy. SETTING PARTICIPANTS: Nursing home residents in 31 Italian nursing homes. MEASUREMENT Each resident underwent a comprehensive geriatric assessment at baseline, and after 6 months and 1 year by means of the RAI MDS 2.0. Facility characteristics were collected using an ad hoc designed questionnaire. Hospitalizations were self-reported by facilities. RESULTS A total of 170 (11.6%) of 1466 nursing home residents were admitted to the hospital at least once during the study period. Female gender and higher physician, nurse, and nursing assistant hours per resident were predictive of a lower probability to be admitted to the hospital, whereas a diagnosis of arrhythmia, a previous urinary tract infection, and polypharmacy were associated with a higher probability of being hospitalized. CONCLUSION These findings suggest that a reduction of hospitalization of nursing home residents could be achieved by providing an adequate amount of care and optimizing the management of chronic diseases and polypharmacy. This hypothesis should be tested in future clinical trials.

Underrecognition and Undertreatment of Dementia in Italian Nursing Homes

OBJECTIVE To determine the prevalence of dementia diagnoses and the use of antidementia drugs in a cohort of Italian older nursing home (NH) residents. DESIGN Cross-sectional study. SETTING The NH residents participating in 2 studies: the U.L.I.S.S.E. study and the Umbria Region survey. PARTICIPANTS A total of 2215 nursing home residents. MEASUREMENT Each resident underwent a comprehensive geriatric assessment at baseline by means of the RAI MDS 2.0. Dementia diagnosis was based on ICD-9 codes. RESULTS The prevalence of dementia diagnosis according to ICD-9 codes was 50.7% (n = 1123), whereas 312 subjects had cognitive impairment with a cognitive performance scale score ≥3 without a diagnosis of dementia. Only 56 NH residents were treated (5% of the sample) and the main drugs used were cholinesterase inhibitor, whereas only 1 subject was treated with memantine. Limiting our analysis to patients with mild to moderate Alzheimers disease, who are those reimbursed by the public health care system for receiving antidementia drugs, the percentage rose to 11.3%. CONCLUSION These findings demonstrate a high rate of underdiagnosis and undertreatment of dementia in Italian NH residents. Potential explanations include the lack of systematic assessment of cognitive functions, the limitations to antidementia drug reimbursement, the complexity of the reimbursement procedure itself, and the high prevalence of patients with severe dementia. Older NH residents still lack proper access to state-of-the-art diagnosis and treatment for a devastating condition such as dementia.

Inappropriate Drug Prescriptions among Older Nursing Home Residents: The Italian Perspective

Older people take up a large proportion of health care, including drugs, and evidence shows that drug prescribing to this group is often inappropriate. Negative consequences of potential inappropriate drug prescription (PIDP) include adverse drug events, high healthcare service utilization and high costs for the patients and society. Although nursing home residents are the most vulnerable persons exposed to PIDP, few observational studies have investigated the prevalence, the factors associated with and the consequences of PIDP. Epidemiological studies assessing PIDP mainly based on the Beers’ criteria showed that approximately half of US and Canadian nursing home residents have at least one PIDP in this setting. The most frequent inappropriate prescriptions concern neuroleptics and long-term benzodiazepines. Nursing home residents aged 80 years or more, those taking a low number of drugs, cognitive or communication problems are less exposed to PIDP compared with residents younger than 80 years, living in facilities with a high number of beds and a lower registered nurse-to-resident ratio. In European countries, the prevalence of PIDP among older nursing home residents was comparable to or higher than that observed in US and Canadian nursing homes. To date, the issue of PIDP has never been investigated in a representative sample of Italian nursing home residents. In a preliminary study performed by our group in 496 nursing home residents randomly selected from 40 nursing homes in Umbria, the prevalence of residents taking at least one or two inappropriate medications was 28% and 7%, respectively. The prevalence of PIDP considering diagnosis (18%) as well as those regardless of diagnosis (17%), as determined by Beers’ criteria, were equally distributed in older Italian nursing home residents and no difference was found between sexes. Overall, this review reveals that the prevalence of PIDP is high in both North American and European nursing homes and highlights the urgent need for intervention trials testing strategies to reduce the health and social burden of PIDP.

Validation of the Italian version of the falls efficacy scale international (FES-I) and the short FES-I in community-dwelling older persons.

Fear of falling (FF) is a common problem in older persons. FF negatively affects the quality of life by generating anxiety, loss of confidence and of self-efficacy, and, ultimately, activity restriction and increased risk of falling. The FES-I and Short FES-I are two instruments developed to assess FF in older persons which have been already validated in some European countries. Our objectives are to develop the Italian version of FES-I and the Short FES-I and to validate them in older persons. The back translation protocol adopted by the ProFaNE group was used to translate both scales from English to Italian. Participants were 157 community-dwelling persons aged>65 years who underwent comprehensive geriatric assessment, including a structured interview concerning FF, and were administered the FES-I and the Short FES-I. Both scales were re-tested after 4 weeks in 151 persons. FES-I and Short FES-I had high internal validity and test-retest reliability. The Short FES-I is highly comparable with the FES-I. We conclude that the FES-I and the Short FES-I are excellent instruments to asses FF in Italian older subjects and they may be used in future research projects and clinical trials.

The Prevention of Adverse Drug Reactions in Older Subjects

Adverse drug reactions (ADRs) are a public health problem in older subjects, being responsible for a significant morbidity, disability and mortality. Older subjects are more susceptible to develop ADRs mainly due to polypharmacy, multimorbidity and inappropriate prescribing. The prevention of these drug related negative events represents an important aim for physicians treating older patients. Several strategies could potentially be employed, including state of the art education of medical students and physicians concerning principles of geriatric medicine and appropriate prescription in older subjects, reduction of inappropriate drug use by means of computerized decision support systems, pharmacist involvement and comprehensive geriatric assessment, and finally the identification of at risk older patients. However, there is currently a lack of scientific evidence demonstrating that these strategies can achieve a reduction in ADRs and therefore future intervention studies should be performed to evaluate the best intervention to decrease the burden of drug related problems in the older population.

Subsyndromal Delirium and Its Determinants in Elderly Patients Hospitalized for Acute Medical Illness

BACKGROUND In older individuals, acute medical illnesses and admission to hospital are often associated with a deterioration of cognitive status, also in the absence of dementia and full-blown delirium. We evaluated the prevalence of subsyndromal delirium (SSD) and its correlates in a sample of elderly medical inpatients. METHODS From 763 consecutive inpatients, 325 participants with known dementia or delirium were excluded, whereas 438 (mean age: 80.6 years; female participants: 60.1%) were enrolled. SSD was diagnosed within 48 hour from admission, when at least two DSM-IV delirium criteria including disorientation, attention or memory deficit, altered level of consciousness, or perceptual disturbances were present. Cognitive performance was evaluated by Mini Mental Status Examination (MMSE). General, clinical, and laboratory parameters were also registered. RESULTS One hundred and sixty-six patients (37%) had SSD. Compared with controls, SSD patients were older individuals, had less formal education, higher comorbidity, lower hemoglobin/lymphocytes counts, and higher creatinine levels. A trend toward higher prevalence of previous stroke and widowhood was observed. A MMSE score of less than 24/30 identified SSD with 88% sensitivity and 78% specificity. In SSD patients, MMSE independently correlated with years of education, high-sensitivity C reactive protein levels, and O2 arterial saturation (model adjusted r (2) = 0.30, p = .001); conversely, only years of education were associated with MMSE in controls (adjusted r (2) = 0.06, p = .01). CONCLUSIONS Our data suggest that SSD is common in hospitalized older medical inpatients, and low MMSE score might be useful for identification of participants at risk of SSD. Current inflammatory response and reduced O2 arterial saturation were the only independent determinants of cognitive performance in SSD patients.

Are ongoing trials on hematologic malignancies still excluding older subjects

Hematologic malignancies are diseases that mainly affect older subjects. Multiple myeloma,[1][1] myelodysplastic syndromes[2][2] and chronic myeloid leukemia[3][3] are common in advanced age. Nevertheless, there is evidence that older patients with hematologic malignancies have often been excluded

Potentially preventable visits to the emergency department in older adults: Results from a national survey in Italy

Background Despite older adults use emergency department more appropriately than other age groups, there is a significant share of admissions that can be considered potentially preventable. Objective To identify socio-demographic characteristics and health care resources use of older adults admitted to emergency department for a potentially preventable visit. Design Data come from the Multipurpose Survey “Health conditions and use of health services”, edition 2012–2013. A stratified multi-stage probability design was used to select a sample using municipal lists of households. Subject 50474 community dwelling Italians were interviewed. In this analysis, 27003 subjects aged 65 years or older were considered. Methods Potentially preventable visits were defined as an emergency department visit that did not result in inpatient admission. Independent variables were classified based on the socio-behavioral model of Andersen-Newman. Descriptive statistics and a logistic regression model were developed. Results In the twelve months before the interview 3872 subjects (14.3%) had at least one potentially preventable visit. Factors associated with an increased risk of a potentially preventable visit were older age (75–84 years: OR 1.096, CI 1.001–1.199; 85+years: OR 1.022, CI 1.071–1.391), at least one hospital admission (OR 3.869, IC 3.547–4.221), to waive a visit (OR 1.188, CI 1.017–1.389) or an exam (OR 1.300, CI 1.077–1.570). Factors associated with a lower risk were female gender (OR 0.893, CI 0.819–0.975), area of residence (Center: OR 0.850; CI 0.766–0.943; Islands: OR 0.617, CI 0.539–0.706, South: OR 0.560; CI 0.505–0.622), private paid assistance (OR 0.761, CI 0.602–0.962); a better health-related quality of life (PCS score 46–54: OR 0.744, CI 0.659–0.841; PCS score >55: OR 0.746, CI 0.644–0.865). Conclusions Our study identified several characteristics associated with an increased risk of potentially preventable visits to the emergency department. This might allow the development of specific interventions to prevent the access of at risk subjects to the emergency department.

Older adults in Emergency Departments: the challenge of undertriage

Older adults account for an increasing proportion of Emergency Department (ED) visits, ranging from 12–24 % of all visits per year [1]. They use a greater number of resources, stay longer in the ED, and have a higher rate of hospitalization than any other age group. Furthermore, older ED patients are a vulnerable patient group at risk of undertriage [2]. Undertriage is the assignment of a low triage level that is functionally inadequate compared to actual urgency/emergency severity, which causes a delay in treatment. The causes of undertriage are probably multifactorial. For instance, vital signs can be normal even in serious disease. Moreover, older patients often present with non-specific complaints, such as weakness, which may lead to undertriage. We aimed to assess the prevalence of undertriage in a sample of older adults consecutively seen in an ED, and to describe the associated factors. A retrospective single-center cohort study was carried out with administrative data of ED visits at the 200 bed, Principe di Piemonte Hospital, in Senigallia (AN), Italy. This ED cares for an average of about 30,000 patients per year. We analyzed the admissions in 1 year, from January 1st to December 31th, 2012. At admission, every patient undergoes triage by a skilled nurse, receiving a color tag based on the Italian triage guidelines [3]. Under the current guidelines, there are four levels of severity: white tag (non-urgent condition); green tag (less urgent condition/low priority); yellow tag (urgent, potentially life-threatening emergency condition); or red tag (very critical, immediately life-threatening emergency condition). The admission tag is assessed to determine the acceptable time delay before the patient should be seen: level 1 (red tag) patients should be evaluated immediately; level 2 (yellow tag) patients should receive medical evaluation within 20 min; level 3 (green tag) patients should be evaluated within 2 h; and finally, at level 4 (white tag), there is no time limit for patients to be evaluated. The reason for an ED visit can be classified into different categories. In our setting, there were 22 groups of symptoms/ problems: unspecified complaints, dyspnoea, trauma, pain (excluding cardiac and abdominal pain), chest pain, abdominal pain, headache, fever, allergic reaction, wheezing, burn, dizziness, head injury, syncope, shock, social problems, need of a particular specialist (gynaecologist, ophthalmologist, ear nose throat specialist), bleeding, epilepsy, coma, asthenia, and legal issues. At discharge (to a ward, to another hospital or to home), the physician assigns a color tag that indicates the clinical severity of the patient (after medical evaluation, diagnostic tests, and treatment). The discharge diagnosis is coded using ICD-9CM codes. We compared the triage tag code, which establishes the priority, with the discharge code, which indicates the severity, and considered a case of undertriage to occur & Beatrice Gasperini beatricegasperini@hotmail.com