Emmae N. Ramsay

Hormone therapy, timing of initiation, and cognition in women aged older than 60 years: the REMEMBER pilot study.

Objective:The aim of this pilot study was to assess any trends related to the timing of initiation, and duration, of hormone therapy (HT) use on cognitive function to facilitate the design and power calculations for a future large cohort study entitled Research into Memory, Brain function and Estrogen Replacement (REMEMBER). Design:A total of 428 women aged older than 60 years were recruited from a computer-generated random selection of Adelaide households. Demographic and lifestyle characteristics, and HT use history were recorded and confirmed. The Center for Epidemiological Studies-Depression score was used to assess mood. Cognitive tests were administered measuring global cognition (Mini-Mental State Examination), attention and concentration (Trail Making Test Parts A and B), verbal learning and memory (Consortium to Establish a Registry for Alzheimers Disease [CERAD] word list immediate and delayed recall), and verbal expression (letter fluency [FAS], category fluency [Animals], and the Boston Naming Test [short form]). Analyses were adjusted for age, education, mood, body mass index, smoking, alcohol intake, and history of cerebrovascular disease. HT use was defined as the use of systemic HT for at least 1 year. Early initiation of HT use was defined as commencement of HT before age 56 years for women with a uterus and ovaries, or within 5 years of a hysterectomy and bilateral oophorectomy. Late initiation of HT use was defined as HT commencing after these times. Results:Early initiators of HT performed better than late initiators on the Mini-Mental State Examination (P = 0.04) and were faster than never users on the Trail Making Test Part A (P = 0.02). Women aged 70-79 years who initiated HT early performed better on the FAS test than never users (P = 0.0008). Late initiators performed worse than never users on the Mini-Mental State Examination (P = 0.09), and on the FAS test in the 60-69 year (P = 0.06) and 80 years and older (P = 0.095) age groups. However, late initiators performed better than never users on the FAS test in the 70-79 year age group (P = 0.015). HT users of less than 11 years (P = 0.09), HT users of more than 11 years (P = 0.04), and estrogen-only users (P = 0.024) performed faster than never users on the Trail Making Test Part A. Combined estrogen plus progestin users performed better than never users on the Boston Naming Test short form (P = 0.07). Conclusions:For some cognitive domains, early initiation of HT from around menopause may be beneficial, and initiation of HT in late menopause may be detrimental. The timing of the initiation of HT seems critical. To fully test these hypotheses and to further examine these trends by route and type of HT regimen in this population, a study size of 2,500 women would be required.

Validity of medication‐based co‐morbidity indices in the Australian elderly population

Objectives: To determine the validity of two medication‐based co‐morbidity indices, the Medicines Disease Burden Index (MDBI) and Rx‐Risk‐V in the Australian elderly population.

The Effectiveness of Collaborative Medicine Reviews in Delaying Time to Next Hospitalization for Patients With Heart Failure in the Practice Setting Results of a Cohort Study

Background—Randomized controlled trials have demonstrated that collaborative medication reviews can improve outcomes for patients with heart failure. We aimed to determine whether these results translated into Australian practice, where collaborative reviews are nationally funded. Methods and Results—This retrospective cohort study using administrative claims data included veterans 65 years and older receiving bisoprolol, carvedilol, or metoprolol succinate for which prescribing physicians indicated treatment was for heart failure. We compared those exposed to a general practitioner–pharmacist collaborative home medication review with those who did not receive the service. The service includes physician referral, a home visit by an accredited pharmacist to identify medication-related problems, and a pharmacist report with follow-up undertaken by the physician. Kaplan-Meier analyses and Cox proportional hazards models were used to compare time until next hospitalization for heart failure between the exposed and unexposed groups. There were 273 veterans exposed to a home medicines review and 5444 unexposed patients. Average age in both groups was 81.6 years (no significant difference). The median number of comorbidities was 8 in the exposed group and 7 in the unexposed (P<0.0001). Unadjusted results showed a 37% reduction in rate of hospitalization for heart failure at any time (hazard ratio, 0.63; 95% CI, 0.44 to 0.89). Adjusted results showed a 45% reduction (hazard ratio, 0.55; 95% CI, 0.39 to 0.77) among those who had received a home medicines review compared with the unexposed patients. Conclusion—Medicines review in the practice setting is effective in delaying time to next hospitalization for heart failure in those treated with heart failure medicines.

The Effectiveness of Collaborative Medicine Reviews in Delaying Time to Next Hospitalization for Patients With Heart Failure in the Practice SettingCLINICAL PERSPECTIVE

Background—Randomized controlled trials have demonstrated that collaborative medication reviews can improve outcomes for patients with heart failure. We aimed to determine whether these results translated into Australian practice, where collaborative reviews are nationally funded. Methods and Results—This retrospective cohort study using administrative claims data included veterans 65 years and older receiving bisoprolol, carvedilol, or metoprolol succinate for which prescribing physicians indicated treatment was for heart failure. We compared those exposed to a general practitioner–pharmacist collaborative home medication review with those who did not receive the service. The service includes physician referral, a home visit by an accredited pharmacist to identify medication-related problems, and a pharmacist report with follow-up undertaken by the physician. Kaplan-Meier analyses and Cox proportional hazards models were used to compare time until next hospitalization for heart failure between the exposed and unexposed groups. There were 273 veterans exposed to a home medicines review and 5444 unexposed patients. Average age in both groups was 81.6 years (no significant difference). The median number of comorbidities was 8 in the exposed group and 7 in the unexposed (P<0.0001). Unadjusted results showed a 37% reduction in rate of hospitalization for heart failure at any time (hazard ratio, 0.63; 95% CI, 0.44 to 0.89). Adjusted results showed a 45% reduction (hazard ratio, 0.55; 95% CI, 0.39 to 0.77) among those who had received a home medicines review compared with the unexposed patients. Conclusion—Medicines review in the practice setting is effective in delaying time to next hospitalization for heart failure in those treated with heart failure medicines.

Multiple Anticholinergic Medication Use and Risk of Hospital Admission for Confusion or Dementia

To identify the association between use of multiple anticholinergic medications and risk of hospitalization for confusion or dementia.

Collaborative home medicines review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans

What is known and background:  Unintended bleeds are a common complication of warfarin therapy. We aimed to determine the impact of general practitioner–pharmacist collaborative medication reviews in the practice setting on hospitalization‐associated bleeds in patients on warfarin.

Risk of hospitalization for hip fracture and pneumonia associated with antipsychotic prescribing in the elderly: a self-controlled case-series analysis in an Australian health care claims database.

AbstractBackground: Antipsychotics are commonly used in the elderly to treat the behavioural symptoms of dementia. Randomized controlled trial data on the safety of antipsychotics are limited and little is known about the long-term effects of these medicines. Observational studies have investigated the risk of hip fracture and pneumonia associated with the use of antipsychotics, but varying results may be due to lack of control for unmeasured confounding. Objective: The aim of the study was to investigate the risk of hospitalization for hip fracture and pneumonia in elderly subjects exposed to antipsychotic medication using the self-controlled case-series design to control for unmeasured confounding. Methods: The source of data for this study was the Australian Government Department of Veterans’ Affairs Health Care Claims Database. A self-controlled case-series design was used to measure the excess risk of hospitalization for hip fracture and pneumonia after antipsychotic exposure compared with no-exposure over the 4-year period from 2005 to 2008. Results: There was a significantly increased risk of hip fracture 1 week after exposure to typical antipsychotics, and the risk remained significantly raised with >12 weeks of continuous exposure (incidence rate ratio [IRR] 2.19; 95% CI 1.62, 2.95). The risk of hip fracture was highest in the first week after initiation of atypical antipsychotics (IRR 2.17; 95% CI 1.54, 3.06). The risk then declined with longer-term treatment; however, it remained significantly raised with >12 weeks of continuous exposure (IRR 1.43; 95% CI 1.23, 1.66). The risk of hospitalization for pneumonia was raised in all post-exposure periods for both typical and atypical antipsychotics. Conclusions: Antipsychotic use in the elderly is associated with an increased risk of hospitalization for hip fracture and pneumonia. Given the increased risks of morbidity and mortality associated with these outcomes, practitioners should consider these additional risks when prescribing antipsychotics to treat behavioural symptoms of dementia in the elderly.

Prevalence of preventable medication-related hospitalizations in Australia: an opportunity to reduce harm.

OBJECTIVE To identify the prevalence of potentially preventable medication-related hospitalizations amongst elderly Australian veterans by applying clinical indicators to administrative claims data. DESIGN AND SETTING Retrospective cohort study in the Australian veteran population from 1 January 2004 to 31 December 2008. PARTICIPANTS A total of 109 044 veterans with one or more hospitalizations defined by the medication-related clinical indicator set, during the 5-year study period. MAIN OUTCOME MEASURE The prevalence of potentially preventable medication-related hospitalizations as a proportion of all hospitalizations defined by the clinical indicator set. RESULTS During the 5-year study period, there were a total of 1 630 008 hospital admissions of which 216 527 (13.3%) were for conditions defined by the medication-related clinical indicator set for 109 044 veterans. The overall proportion of potentially preventable medication-related hospitalizations was 20.3% (n= 43 963). Of the 109 044 veterans included in the study, 28 044 (25.7%) had at least one potentially preventable medication-related hospitalization and 7245 (6.6%) veterans had two or more potentially preventable admissions. Conditions with both a high prevalence of hospitalization and preventability included asthma/chronic obstructive pulmonary disorder, depression and thromboembolic cerebrovascular event (23.3, 18.5 and 18.3%, respectively, were potentially preventable). Other hospitalizations that were less common but had a high level of preventability (at least 20%) included hip fracture, impaction, renal failure, acute confusion, bipolar disorder and hyperkalaemia. CONCLUSIONS The results of this study highlight those conditions where hospitalizations could potentially be avoided through improved medication management. Strategies to increase the awareness, identification and resolution of these medication-related problems contributing to these hospitalizations are required in Australia.

Comorbid chronic diseases, discordant impact on mortality in older people: a 14-year longitudinal population study

Objectives To determine the impact of comorbid chronic diseases on mortality in older people. Design Prospective cohort study (1992–2006). Associations between numbers of chronic diseases or mutually exclusive comorbid chronic diseases on mortality over 14 years, by Cox proportional hazards model adjusting for sociodemographic variables or Kaplan–Meier analyses, respectively. Setting Population based, Australia. Participants 2087 randomly selected participants aged ≥65 years old, living in the community or institutions. Main results Participants with 3–4 or ≥5 diseases had a 25% (95% CI 1.05 to 1.5, p=0.01) and 80% (95% CI 1.5 to 2.2, p<0.0001) increased risk of mortality, respectively, by comparison with no chronic disease, after adjusting for age, sex and residential status. When cardiovascular disease (CVD), mental health problem or diabetes were comorbid with arthritis, there was a trend towards increased survival (range 8.2–9.5 years) by comparison with CVD, mental health problem or diabetes alone (survival 5.8–6.9 years). This increase in survival with arthritis as a comorbidity was negated when CVD and mental health problems or CVD and diabetes were present in disease combinations together. Conclusion Older people with ≥3 chronic diseases have increased risk of mortality, but discordant effects on survival depend on specific disease combinations. These results raise the hypothesis that patients who have an increased likelihood of opportunity for care from their physician are more likely to have comorbid diseases detected and managed.

Major bleeding risk associated with warfarin and co‐medications in the elderly population

Warfarin management in the elderly population is complex as medicines prescribed for concomitant diseases may further increase the risk of major bleeding associated with warfarin use. We aimed to quantify the excess risk of bleeding‐related hospitalisation when warfarin was co‐dispensed with potentially interacting medicines.