Nikesh Parekh

A practical approach to the pharmacological management of hypertension in older people

Hypertension is the leading cause of cardiovascular (CV) morbidity and mortality in adults over the age of 65. The first part of this paper is an overview, summarizing the current guidelines on the pharmacological management of hypertension in older adults in Europe and the USA, and evidence from key trials that contributed to the guidelines. In the second part of the paper, we will discuss the major challenges of managing hypertension in the context of multimorbidity, including frailty, orthostatic hypotension (OH), falls and cognitive impairment that are associated with ageing. A novel ‘BEGIN’ algorithm is proposed for use by prescribers prior to initiating antihypertensive therapy to guide safe medication use in older adults. Practical suggestions are highlighted to aid practitioners in making rational decisions to treat and monitor hypertension, and for considering withdrawal of antihypertensive drugs in the complex older person.

Can supporting health literacy reduce medication-related harm in older adults?:

More people than ever before are living into old age. The increased longevity is partly due to the increased use of medicines. Despite the potential benefits of medicines, they can still cause significant harm. Medication-related harm (MRH) may be from adverse drug reactions or harm from inappropriate drug use, for example, nonadherence or medication error. The European Commission estimated in 2008 that MRH contribute to at least 100,800 deaths in member states annually and costs society €79 billion.1 Older adults are most at risk due to their high exposure to medicines and age-related pharmacokinetic and pharmacodynamic changes. A recent systematic review found that 1 in 10 hospitalized older adults are admitted due to MRH, and approximately the same proportion experience MRH as an inpatient.2 Avoidable health service use due to MRH is substantial. A study in the Netherlands estimated the average cost of an avoidable MRH hospitalization in an older adult at €5500.3 Top-down interventions to reduce MRH and unplanned admissions, such as pharmacist-led medicines review, have shown limited effectiveness. There is a need to consider a bottom-up approach, exploring patient-centred modifiable determinants. Health literacy is one such determinant that is being explored in relation to MRH. A survey of eight countries in the European Union (EU) found that 30–60% of people are not health literate, with the older population representing a particularly high-risk group.4 A ‘mandate’ to enhance health literacy has been sent out to policy- makers in the 2016 World Health Organization (WHO) 9th Global Conference on Health Promotion. In this editorial we consider how health literacy can be conceptualized as a fundamental principle in reducing MRH in the older adult.

Incidence of medication-related harm in older adults following hospital discharge: A systematic review

To determine the incidence, severity, and preventability of and risk factors for medication‐related harm (MRH) in community‐dwelling older adults after hospital discharge.

Incidence and cost of medication harm in older adults following hospital discharge: a multicentre prospective study in the UK

Polypharmacy is increasingly common in older adults, placing them at risk of medication‐related harm (MRH). Patients are particularly vulnerable to problems with their medications in the period following hospital discharge due to medication changes and poor information transfer between hospital and primary care. The aim of the present study was to investigate the incidence, severity, preventability and cost of MRH in older adults in England postdischarge.

Exploring the enablers and barriers to implementing the Medication Appropriateness Tool for Comorbid Health conditions during Dementia (MATCH-D) criteria in Australia: a qualitative study

Objectives The Medication Appropriateness Tool for Comorbid Health conditions in Dementia (MATCH-D) criteria provide expert consensus guidance about medication use for people with dementia. This study aimed to identify enablers and barriers to implementing the criteria in practice. Setting Participants came from both rural and metropolitan communities in two Australian states. Participants Focus groups were held with consumers, general practitioners, nurses and pharmacists. Outcomes: data were analysed thematically. Results Nine focus groups were conducted. Fifty-five participants validated the content of MATCH-D, appraising them as providing patient-centred principles of care. Participants identified potential applications (including the use of MATCH-D as a discussion aid or educational tool for consumers about medicines) and suggested supporting resources. Conclusion Participants provided insights into applying MATCH-D in practice and suggested resources to be included in an accompanying toolkit. These data provide external validation of MATCH-D and an empiric basis for their translation to practice. Following resource development, we plan to evaluate the feasibility and efficacy of implementation in practice.

Can doctors identify older patients at risk of medication harm following hospital discharge? A multicentre prospective study in the UK

Medication‐related harm (MRH) is common in older adults following hospital discharge. In resource‐limited health systems, interventions to reduce this risk can be targeted at high‐risk patients. This study aims to determine whether (1) doctors can predict which older patients will experience MRH requiring healthcare following hospital discharge, (2) clinical experience and confidence in prediction influence the accuracy of the prediction.

[Abstract] Aortic stiffness and central systolic pressure are associated with orthostatic hypotension in patients with chronic kidney disease

Orthostatic hypotension (OH) is common cardiovascular problem affecting older adults, and is associated with falls, stroke and chronic kidney disease (CKD). This postural drop (PD) in blood pressure (BP) has been independently associated with increased aortic stiffness in older adults. Aortic stiffness is a modifiable cardiovascular risk factor, and measureable non-invasively. We investigated the association between OH, aortic stiffness and central aortic systolic pressure (CSP) in CKD patients (ACADEMIC cohort). Design and method: Postural BP changes were measured in one-hundred and forty-six patients (mean age 68.6 SD±11.4, 75% male, 21% diabetic) using 24-hour-ambulatory blood pressure monitoring with postural sensing (Diasys Integra II®, Novacor, France). Patients were divided into those with systolic postural drop (SPD, n=23, mean standing systolic BP<mean lying systolic BP) versus those without (n=123). Complior® (Artech Medical, France) measured aortic stiffness as carotid-femoral pulse wave velocity (cf-PWV) and peripheral arterial stiffness as carotid-radial PWV (cr-PWV). Sphygmocor® (Atcor, Australia) measured CSP and augmentation index (AI) from the radial artery. Results: Cf-PWV and CSP were significantly higher in CKD patients with SPD versus those without (15.2m/s vs 12.7m/s, p<0.001, 148mmHg vs 136mmHg, p=0.012). Multivariate logistic regression showed SBP remained significantly associated with aortic stiffness (p=0.002, OR=1.45 95%CI=1.15-1.77) and CSP (p=0.026, OR=1.031, 95%CI=1.00-1.06), independent of age, eGFR, diabetes, smoking pack-years, cholesterol, height and weight. RAI (32.1%vs28.9%, p=0.093) and cr-PWV (11.0m/s vs 11.2m/s, p=0.62) were not significantly different between groups. Conclusion: Increased aortic stiffness and CSP are independently associated with OH. Stiff central arteries, rather than peripheral, contribute more to OH.

The most vulnerable refugees are not in Europe.

Remember the millions of people camped on Syria’s borders