Regina Roller-Wirnsberger

Potentially inappropriate medication in geriatric patients: the Austrian consensus panel list

ZusammenfassungHINTERGRUND: Bei geriatrischen Patienten stellen inadäquate Medikamentenverordnungen einen wichtigen Risikofaktor für unerwünschte Arzneimittelereignisse dar. Sie führen in diesem Zusammenhang zu einer Zunahme von Spitalszuweisungen, welche die Gesundheitskosten belasten. Die Entwicklung Konsensus-basierter Listen von Medikamenten, die bei geriatrischen Patienten im Allgemeinen vermieden werden sollten, wird als eine mögliche Strategie angesehen, um die Qualität der medikamentösen Behandlung zu steigern. ZIEL: Erstellung einer, den österreichischen Verschreibungsgewohnheiten und der Marktsituation angepassten, Konsensus-basierten Liste von Arzneimitteln, deren Verordnung potentiell inadäquat für geriatrische Patienten ist, und die deshalb vermieden werden sollten. METHODE: Als Evaluierungsmethode wurde ein zwei-stufiger Delphi Prozess gewählt, an dem acht Experten mit Erfahrung in der medikamentösen Therapie geriatrischer Patienten teilnahmen. In der ersten Runde bewerteten die Experten Medikamente einer vorgegebenen Liste anhand einer 5-stufigen Likert Skala von sicher potentiell unangemessen bis sicher nicht potentiell unangemessen. Alle Medikamente, für deren Bewertung die obere Grenze des 95 % Konfidenzintervalls unter 3,0 lag, wurden als potentiell unangemessen klassifiziert. Medikamente, deren 95 % KI den Wert 3,0 umschloss, wurden in der zweiten Runde wieder anhand einer 5-stufigen Likert Skala bewertet, ebenso wie die in der ersten Runde neu vorgeschlagenen Medikamente. Nach Analyse der Ergebnisse der zweiten Runde wurde die finale Liste erstellt. RESULTATE: Von den vorgegebenen 102 Medikamenten wurden 61 Medikamente (59,2 %) bereits in der ersten Runde als potentiell unangemessen für ältere Menschen eingestuft. Sechs Medikamente, die in der zweiten Runde erneut evaluiert wurden, und sechs in der ersten Runde neu vorgeschlagene Medikamente wurden in der zweiten Runde als potentiell inadäquat klassifiziert. Die finale Liste enthält 73 Arzneimittel, die aufgrund eines ungünstigen Nutzen/Risiko Profils oder aufgrund fraglicher Wirksamkeit bei geriatrischen Patienten nicht verordnet werden sollten. SCHLUSSFOLGERUNG: Die Österreichische PIM Liste kann für klinisch tätige Ärzte ein in der Praxis anwendbares Instrument darstellen, das zu einer Verbesserung der Qualität von Medikamentenverordnungen bei älteren Patienten beiträgt. Studien zur Validierung der PIM-Liste stehen in Österreich ebenso wie in anderen Ländern mit bereits veröffentlichten PIM-Listen noch aus.SummaryBACKGROUND: The practice of inappropriate medication and drug prescription is a major risk factor for adverse drug reactions in geriatric patients and increases the individual, as well as overall, rates of hospital admissions, resulting in increased health care expenditures. A consensus-based list of drugs, generally to be avoided in geriatric patients, is a practical tool to possibly improve the quality of prescribing. OBJECTIVE: The aim was to develop a consensus-based list of potentially inappropriate medications (PIM) for geriatric patients in Austria. Local market characteristics and documented prescribing regimens were considered in detail. METHODS: A two-round Delphi process involving eight experts in the field of geriatric medicine was undertaken to create a list of potentially inappropriate medications. Using a 5-point Likert scale (from strong agreement to strong disagreement), mean ratings from the experts were evaluated for each drug selected in the first round. The participants were first asked to comment on the potential inappropriateness of a preliminary list of drugs, and to propose alternate substances missing in the previous questionnaire for a second rating process. All drugs whose upper limit of the 95% CI was less than 3.0 were classified as potentially inappropriate. Drugs with a 95% CI enclosing 3.0 entered a second rating by the experts, in addition to other substances suggested during the first questionnaire. Drugs in the second rating were evaluated in comparable fashion to the first one. The final list was synthesized from the results in both rounds. RESULTS: Out of a preliminary list of 102 drugs, 61 drugs (59.2%) were classified as potentially inappropriate for geriatric persons in the first Delphi- round. In the second rating, six drugs that were reevaluated, and six drugs proposed additionally, were rated as potentially inappropriate. The final list contains 73 drugs to be avoided in older patients because of an unfavorable benefit/risk profile and/or unproven effectiveness. The list also contains suggestions for therapeutic alternatives and information about pharmacological and pharmacokinetic characteristics of all drugs judged as potentially inappropriate. CONCLUSION: The current Austrian list of potentially inappropriate medications may be a helpful tool for clinicians to increase the quality of prescribing in older patients. Like all explicit lists previously published, its validity needs to be proven in validation studies.

Prevalence and associations of potentially inappropriate prescriptions in Austrian nursing home residents: secondary analysis of a cross-sectional study

SummaryBackgroundPotentially inappropriate prescriptions (PIP) are an important cause of adverse medication-related events and increases morbidity, hospitalization, and health care costs, especially in nursing home residents. However, little is known about the associations between PIP and residents’ characteristics.ObjectiveThe aim of our study was to analyse the prevalence and associations of PIP with residents’ and facilities’ characteristics.MethodsWe performed a secondary analysis of a cross-sectional study with 48 out of 50 eligible nursing homes and 1,844 out of 2,005 eligible residents in a defined rural-urban area in Austria. The Austrian list of potentially inappropriate medications was applied for the evaluation of inappropriate prescribing. Cluster-adjusted multiple regression analysis was used to investigate institutional and residents’ characteristics associated with PIP.ResultsMean cluster-adjusted prevalence of residents with at least one PIP was 70.3 % (95 % CI 67.2–73.4). The number of residents with at least one psychotropic PIP was 1.014 (55 %). The most often prescribed PIP were Prothipendyl (25.9 % residents), Lorazepam (14.5 %) and Diclofenac (6.1 %). Multiple regression analysis showed an inverse association of PIP with cognitive impairment and significant positive associations with permanent restlessness and permanent negative attitude. The associations of PIP with age and male gender were inconsistent. No significant associations were found for PIP and the ratio of staff nurses to residents.ConclusionsOur study results confirm that PIP is highly prevalent in the nursing home population. These results urgently call for effective interventions. Initiatives and successful interventions performed in other countries could serve as examples for safer prescribing in residents in Austria.ZusammenfassungGrundlagenPotentiell unangemessene Medikamentenverordnungen (potentially inappropriate prescriptions = „PIP“) sind eine bedeutende Ursache von unerwünschten Arzneimittel-assoziierten Wirkungen und führen zu vermehrten Kosten im Gesundheitssystem und vor allem bei Pflegeheimbewohnern zu erhöhter Morbidität und Spitalseinweisungen.Wenig ist bisher bekannt über die Zusammenhänge zwischen PIP und den Charakteristika von Pflegeheimbewohnern.ZielZiel unserer Studie war es, die Prävalenz und Assoziationen von PIP mit den Charakteristika der Bewohner und Pflegeheime zu analysieren.MethodikWir führten eine Sekundäranalyse einer Querschnittsstudie mit 48 von 50 möglichen Pflegeheimen und 1844 von 2005 möglichen Bewohnern eines definierten Bundeslandes in Österreich durch. Die Evaluierung der unangemessenen Verordnungen erfolgte anhand der „Österreichischen Liste der potentiell unangemessenen Arzneimittel“.Cluster-adjustierte multivariate Regressionsanalyse wurde angewandt, um die Assoziationen von PIP mit Charakteristika der Institutionen und Bewohner auszuwerten.ErgebnisseDie mittlere cluster-adjustierte Häufigkeit von Heimbewohnern mit mindestens einem PIP war 70,3 % (95 % CI 67,2–73,4). Die Anzahl der Bewohner mit mindestens einer psychotropen PIP war 1,014 (55 %). Die häufigsten PIP waren Prothipendyl (25,9 % der Bewohner), Lorazepam (14,5 %) und Diclofenac (6,1 %). Multivariate Regressionsanalyse zeigte eine inverse Assoziation von PIP mit kognitiver Einschränkung und signifikant positive Assoziationen mit ständiger Unruhe und ständigem negativem Verhalten der Bewohner.Die Assoziationen von PIP mit Alter und männlichem Geschlecht zeigten uneinheitliche Resultate. Keine signifikanten Assoziationen wurden zwischen PIP und dem Betreuungsverhältnis zwischen Pflegepersonen und Heimbewohnern gefunden.SchlussfolgerungenUnsere Studienresultate bestätigen, dass PIP bei Pflegeheimbewohnern weit verbreitet ist und zeigen, dass dringend effektive Strategien zur Reduktion von PIPs in Österreich notwendig sind. In anderen Ländern bereits durchgeführte erfolgreiche Initiativen und Interventionen könnten als Beispiele für Österreich herangezogen werden.

Muscle power and nutrition.

Sarcopenia, as defined by the European working group on sarcopenia in older people (EWGSOP), is a highly prevalent syndrome characterized by age-related loss of muscle mass and muscle strength/power with impacts on physical function, health and quality of life in older people. The complex, multifaceted and still not completely elucidated etiology of sarcopenia and loss of muscle function (dynapenia) poses challenges for the design of interventional studies to combat loss of muscle strength. Several factors, however, have been demonstrated to have major impacts for maintenance of physiological muscle functioning, including nutrition and in particular specific nutrients. For example, proteins, amino acids and micronutrients have been extensively studied regarding their impact on muscle synthesis and metabolism. This literature review focuses on the impact of nutrition on muscle strength and power as it relates to older people given that muscle changes with age can have important implications for health.ZusammenfassungSarkopenie ist ein häufiges Syndrom bei älteren Menschen, welches von der European Working Group on Sarcopenia in Older People (EWGSOP) durch eine altersbedingte Abnahme der Muskelmasse und Muskelkraft bzw. -leistung charakterisiert wird. Sarkopenie hat negative Auswirkungen auf die körperliche Funktionsfähigkeit, Gesundheit und Lebensqualität älterer Menschen. Die komplexe und noch immer nicht vollständig verstandene Ätiologie der Sarkopenie und des Verlusts der muskulären Funktion (Dynapenie) ist eine Herausforderung bei der Konzeption von Interventionsstudien. Für mehrere Faktoren konnte bereits gezeigt werden, dass sie die Erhaltung der physiologischen Muskelfunktion wesentlich beeinflussen. Hierzu zählen die Ernährung und insbesondere spezielle Nährstoffe. So wurden beispielsweise Proteine, Aminosäuren und Mikronährstoffe gründlich bezüglich ihres Effekts auf Bildung und Stoffwechsel der Muskulatur untersucht. Das Ziel dieser Literaturübersicht ist es, den Einfluss der Ernährung auf die Muskelkraft und -leistung älterer Menschen darzustellen.

Der geriatrische Patient in der Notaufnahme

Notfall Rettungsmed 2016 · 19:496–499 DOI 10.1007/s10049-016-0216-z Online publiziert: 1. September 2016

Frailty and multimorbidity: a systematic review and meta-analysis

Background Multimorbidity and frailty are complex syndromes characteristics of ageing. We reviewed the literature, and provided pooled estimations of any evidence regarding a) the coexistence of frailty and multimorbidity, and b) their association. Methods We searched PubMed and Web of Science for relevant articles up to September 2017. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting. Homogeneity (I2), risk of bias and publication bias were assessed. PROSPERO registration: 57890. Results A total of 48 studies involving 78122 participants were selected, and 25 were included in one or more meta-analyses. Forty-five studies were cross-sectional and 3 longitudinal, with the majority of them including community-dwelling participants (n=35). Forty-three studies presented a moderate risk of bias, and 5 a low risk. Most of the articles defined multimorbidity as having two or more diseases and frailty according to the Cardiovascular Health Study criteria. In meta-analyses, the prevalence of multimorbidity in frail individual was 72% (95% Confidence Interval [95% CI] 63% to 81%; I2=91.3%) and the prevalence of frailty among multimorbid individuals was 16% (95% CI 12% to 21%; I2=96.5%). Multimorbidity was associated with frailty in pooled analyses (OR 2.27; 95% CI 1.97 to 2.62; I2 47.7%). The three longitudinal studies suggest a bidirectional association between multimorbidity and frailty. Conclusions Frailty and multimorbidity are two related conditions in older adults. Most frail individuals are also multimorbid but fewer multimorbid ones present also frailty. Our findings are not conclusive regarding the causal association between the two conditions. Further longitudinal and well-designed studies may help to untangle the relationship between frailty and multimorbidity.

Bilateral leg edema in an older woman

Bilateral leg edema is a frequent symptom in older people and an important concern in geriatric medicine. Further evaluation is frequently not performed and simple therapy with diuretics is prescribed. Particularly in older patients, long-term use of diuretics can lead to severe electrolyte imbalances, volume depletion, and falls.In this case report we want to focus the physicians’ attention on the necessity to determine the cause and show a correspondingly effective treatment for bilateral leg edema in older people. A thorough approach is required to recognize diseases and to avoid adverse drug events as geriatric patients often show an atypical presentation or minor symptoms. The cause of swollen legs is often multifactorial; therefore, the patient’s individual history and an appropriate physical examination are important. Depending on the clinical symptoms, evaluation including basic laboratory tests, urinalysis, chest radiography, and echocardiogram may be indicated.The most probable cause of bilateral edema in older patients is chronic venous insufficiency. Heart failure is also a common cause. Other systemic causes such as renal disease or liver disease are much rarer. Antihypertensive and anti-inflammatory drugs can frequently cause leg edema, but the incidence of drug-induced leg swelling is unknown. With the help of this special case we tried to develop an approach to the diagnosis of symmetric leg edema in older patients, a problem frequently neglected in geriatric medicine.ZusammenfassungBeidseitige Beinödeme sind ein häufiges Symptom bei älteren Patienten. Oftmals wird auf eine weitere Abklärung verzichtet und eine einfache Therapie mit Diuretika vorgenommen. Diese Vorgehensweise kann zu gefährlichen Komplikationen wie Elektrolytentgleisungen, Exsikkose und Stürzen führen. Mithilfe dieses Fallberichtes soll auf die Notwendigkeit einer kausalen Abklärung von Beinödemen bei geriatrischen Patienten aufmerksam gemacht und eine effektive Therapie beschrieben werden. Besondere Aufmerksamkeit ist geboten, um die möglichen Grunderkrankungen und Medikamentennebenwirkungen zu erkennen, da gerade ältere Patienten häufig nur geringe oder atypische Symptome aufweisen.Die Gründe für das Auftreten von beidseitigen Beinödemen sind bei alten Menschen häufig multifaktoriell. Daher ist eine genaue Anamnese und eine entsprechende körperliche Untersuchung wichtig. Laboruntersuchungen, eine Urinanalyse, eine Röntgenuntersuchung des Thorax, ein EKG und eventuell eine Echokardiographie können abhängig von den klinischen Symptomen erforderlich sein.Die wahrscheinlichste Ursache für beidseitige Beinschwellungen bei älteren Patienten ist die chronisch-venöse Insuffizienz. Herzinsuffizienz ist die zweithäufigste Ursache. Die anderen systemisch-organischen Ursachen wie Nieren- und Lebererkrankungen sind wesentlich seltener. Blutdrucksenkende und entzündungshemmende Medikamente können ebenfalls oft geschwollene Beine verursachen, wobei die Inzidenz der medikamentös-induzierten Beinödeme nicht bekannt ist. Mithilfe dieses speziellen Falles wird eine Annäherung an die oftmals zu wenig beachtete Problematik beidseitiger Beinödeme bei älteren Menschen versucht.

Introduction: Age-Attuning Medical Education, Fostering Geriatric Thinking

From the demographic perspective, the world population is not only aged (with a global life expectancy of 71.4 years, WHO 2016), but it is also at risk of (or suffering from) multimorbidity and related disability (Table 1.1). The latter are highly prevalent through the third phase of the epidemiologic transition, characterized by reduced mortality rates together with a unique ageing rate of the population. As multimorbidity predicts 5-year mortality and disability, multimorbid subjects must expect to live 12–17 years disabled (Table 1.1).

The “Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies” (SPRINTT) randomized controlled trial: Case finding, screening and characteristics of eligible participants

Background: The ongoing “Sarcopenia and Physical fRailty IN older people: multi‐componenT Treatment strategies (SPRINTT)” randomized controlled trial (RCT) is testing the efficacy of a multicomponent intervention in the prevention of mobility disability in older adults with physical frailty & sarcopenia (PF&S). Here, we describe the procedures followed for PF&S case finding and screening of candidate participants for the SPRINTT RCT. We also illustrate the main demographic and clinical characteristics of eligible screenees. Methods: The identification of PF&S was based on the co‐occurrence of three defining elements: (1) reduced physical performance (defined as a score on the Short Physical Performance Battery between 3 and 9); (2) low muscle mass according to the criteria released by the Foundation for the National Institutes of Health; and (3) absence of mobility disability (defined as ability to complete the 400‐m walk test in 15 min). SPRINTT was advertised through a variety of means. Site‐specific case finding strategies were developed to accommodate the variability across centers in catchment area characteristics and access to the target population. A quick “participant profiling” questionnaire was devised to facilitate PF&S case finding. Results: During approximately 22 months, 12,358 prescreening interviews were completed in 17 SPRINTT sites resulting in 6710 clinic screening visits. Eventually, 1566 candidates were found to be eligible for participating in the SPRINTT RCT. Eligible screenees showed substantial physical function impairment and comorbidity burden. In most centers, project advertisement through mass media was the most rewarding case finding strategy. Conclusion: PF&S case finding in the community is a challenging, but feasible task. Although largely autonomous in daily life activities, older adults with PF&S suffer from significant functional impairment and comorbidity. This subset of the older population is therefore at high risk for disability and other negative health‐related events. Key strategies to consider for successfully intercepting at‐risk older adults should focus on mass communication methods.

Estimated glomerular filtration rate and functional status among older people : A systematic review.

BACKGROUND The association between chronic kidney disease (CKD) and functional status may change as a function of the equation used to estimate glomerular filtration rate (eGFR). We reviewed the predictive value of different eGFR equations in regard to frailty and disability outcomes. METHODS We searched Pubmed from inception to March 2018 for studies investigating the association between eGFR and self-reported and/or objective measures of frailty or disability. Cross-sectional and longitudinal studies were separately analysed. RESULTS We included 16 studies, one of which reporting both cross-sectional and longitudinal data. Three out of 7 cross-sectional studies compared different eGFR equations in regard to their association with functional status: two studies showed that cystatin C-based, but not creatinine-based eGFR may be associated with hand-grip strength or frailty; another study showed that two different creatinine-based eGFR equations may be similarly associated with disability. Four out of 10 longitudinal studies provided comparative data: two studies reported similar association with disability for different creatinine-based eGFR equations; one study showed that creatinine-based eGFR was not associated with frailty, but a not significant trend for association was observed with cystatin C-based eGFR; one study showed that cystatin C-based but not creatinine-based eGFR may predict incident mobility disability, while both methods may predict gait speed decline. High heterogeneity was observed in regard to confounders included in reviewed studies. None of them included the most recently published equations. CONCLUSION Available data do not support the superiority of one of the eGFR equations in terms of measuring or predicting functional decline.

Optimizing medical care for geriatric patients in Austria: defining a top five list of “Choosing Wisely” recommendations using the Delphi technique

PurposeInappropriate use of diagnostic and therapeutic medical procedures is common and potentially harmful for older patients. The Austrian Society of Geriatrics and Gerontology defined a consensus of five recommendations to avoid overuse of medical interventions and to improve care of geriatric patients.MethodsFrom an initial pool of 147 reliable recommendations, 20 were chosen by a structured selection process for inclusion in a Delphi process to define a list of five top recommendations for geriatric medicine. 12 experts in the field of geriatric medicine scored the recommendations in two Delphi rounds.ResultsThe final five recommendations are concerning urinary catheters in elderly patients, percutaneous feeding tubes in patients with advanced dementia, antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia, and screening for breast, colorectal, prostate, or lung cancer, and the use of antimicrobials to treat asymptomatic bacteriuria.ConclusionsThe selected recommendations have the potential to improve medical care for older patients, to reduce side effects caused by unnecessary medical procedures, and to save costs in the health care system.