Susan J. Ogle

The Epidemiology of Serious Adverse Drug Reactions Among the Elderly

Although the incidence and prevalence of serious adverse drug reactions (ADRs) in the elderly cannot be accurately stated, published estimates appear to be unchanged since the earliest reports in the 1960s. Whereas heightened awareness of the problem may weigh in favour of a reduction in ADR frequency, the dramatic increase in the number and availability of therapeutic agents has undoubtedly contributed to the observed high proportion of drug-induced morbidity among acute geriatric hospital admissions. No single drug or drug class is of particular concern since none appears to cause serious morbidity out of proportion with its use.Although numerous studies have sought to identify risk factors for ADRs, the only truly independent predictor is the absolute number of concurrently used medications. However, other studies indicate that there is poor doctor-patient agreement regarding a patient’s drug regimen, and interventions that aim to reduce the incidence of ADRs have failed to demonstrate a positive effect. Thus at present the most rational approach would appear to be to establish an accurate knowledge of the patients drug regimens: once this is known one can attempt to rationally minimise the number of medications without compromising therapeutic goals.

Optimizing the Use of Antithrombotic Therapy for Atrial Fibrillation in Older People: A Pharmacist‐Led Multidisciplinary Intervention

Objectives: To develop, implement, and evaluate a pharmacist‐led multidisciplinary intervention in a hospital setting that would optimize antithrombotic use in elderly atrial fibrillation patients. The hypothesis that there would be an increase in the proportion of patients receiving antithrombotic therapy at discharge was tested.

Reducing Risk of Falling in Older People Discharged From Hospital: A Randomized Controlled Trial Comparing Seated Exercises, Weight-Bearing Exercises, and Social Visits

OBJECTIVE To compare the efficacy of seated exercises and weight-bearing (WB) exercises with social visits on fall risk factors in older people recently discharged from hospital. DESIGN Twelve-week randomized, controlled trial. SETTING Home-based exercises. PARTICIPANTS Subjects (N=180) aged 65 and older, recently discharged from hospital. INTERVENTIONS Seated exercises (n=60), WB exercises (n=60), and social visits (n=60). MAIN OUTCOME MEASURES Primary outcome factors were Physiological Profile Assessment (PPA) fall risk score, and balance while standing (Coordinated Stability and Maximal Balance Range tests). Secondary outcomes included the component parts of the PPA and other physical and psychosocial measures. RESULTS Subjects were tested at baseline and at completion of the intervention period. After 12 weeks of interventions, subjects in the WB exercise group had significantly better performance than the social visit group on the following: PPA score (P=.048), Coordinated Stability (P<.001), Maximal Balance Range (P=.019); body sway on floor with eyes closed (P=.017); and finger-press reaction time (P=.007) tests. The seated exercise group performed better than the social visit group in PPA score (P=.019) but for no other outcome factor. The seated exercise group had the highest rate of musculoskeletal soreness. CONCLUSIONS In older people recently discharged from the hospital, both exercise programs reduced fall risk score in older people. The WB exercises led to additional beneficial impacts for controlled leaning, reaction time, and caused less musculoskeletal soreness than the seated exercises.

The impact of age on antithrombotic use in elderly patients with non-valvular atrial fibrillation

Aim of study: To investigate the use of antithrombotic therapy in elderly patients with atrial fibrillation (AF). Methods: Data were collected retrospectively from the medical records of 262 AF patients >65 years, who were admitted to a Sydney teaching hospital over a 12‐month period.

Evidence of detraining after 12-week home-based exercise programs designed to reduce fall risk factors in older people recently discharged from hospital

OBJECTIVE To measure the extent to which improved sensorimotor function and balance resulting from a 12-week exercise intervention were retained 12 weeks after exercise cessation in older adults recently discharged from hospital. DESIGN Randomized controlled trial with reassessment 12 weeks after exercise cessation. SETTING Home-based exercises. PARTICIPANTS Adults (N=180) aged 65 years and older recently discharged from hospital (mean length of stay, 12.3±10.6d). INTERVENTIONS Weight-bearing (WB) exercises (n=60), seated resistance (SR) exercises (n=60), or social visits (n=60). MAIN OUTCOME MEASURES Physiological Profile Assessment (PPA), a composite sensorimotor fall-risk score, and 2 measures of controlled leaning balance assessed at baseline, immediately after the intervention (12wk, 95% assessed), and again 12 weeks later (24wk, 92% assessed). RESULTS After the initial improvements in outcomes found at 12 weeks, both the SR and WB exercise groups showed detraining effects at 24 weeks. The PPA fall-risk scores for both SR and WB groups returned to close to baseline values, and there was no significant difference between groups at 24 weeks when controlling for baseline scores (P=.924). WB exercise participants lost up to half of the improvement in the maximal balance range and coordinated stability tests. There was no difference between groups for the maximal balance range test at 24 weeks when controlling for baseline scores (P=.207), but between-group differences were maintained for the coordinated stability test (P=.017). CONCLUSIONS Balance improvements and fall-risk reductions associated with a 12-week home-based exercise program in older adults were partially to totally lost 12 weeks after the cessation of the intervention. These significant detraining effects suggest that sustained adherence to falls prevention exercise programs is required to reduce fall risk.

Balancing risk versus benefit: the elderly patient's perspective on warfarin therapy

Warfarin therapy is underused in the target at-risk elderly population. Clinicians perceive that older patients are reluctant to use this therapy, however the perspective of patients or their carers has yet to be explored. Objective: To explore in-depth the perspectives of elderly patients and/or their carers regarding the use of warfarin therapy. Method: A qualitative study, using semi-structured group interviews was undertaken. The audio-taped discussions were transcribed verbatim, then thematically analysed to identify emergent themes. Group discussions were conducted at a major Sydney teaching hospital, over a 2-month period. Individuals aged 65 years or older (and/or their carers) who were using long-term (6 months) warfarin therapy were recruited by voluntary response to study flyers. Results: 17 patients and carers (mean age 77.2 SD=7.5 years) participated in one of two focus groups. Five core themes emerged regarding warfarin therapy: inadequate knowledge and understanding about it, patients/carers variable experience of information provision, cycle of reactions to being on it, issues in its practical management, and the spectrum of experiences with it. Overall, participants were very accepting of the therapy, describing a high level of compliance, despite initial fears and anxieties, and a relative lack of knowledge. Patients felt somewhat abandoned in their management of warfarin due to the lack of ongoing support services in the community, and inadequate information provision. Conclusions: Elderly patients and their carers appear to be quite accepting of warfarin therapy, in contrast to the perceptions of health care professionals. More effort is needed, however, in terms of information provision, particularly in the form of community-based services, to assist patients in the long-term management of warfarin.

Acopia‘: a Useful Term or Not?

Background: ‘Acopia’, meaning inability to cope, is increasingly used by Australian public hospital emergency departments to describe frail older patients. This raises concerns among geriatricians that significant medical illnesses in older people are being misdiagnosed or under diagnosed

Development and pilot testing of the revised Patients' Attitudes Towards Deprescribing questionnaire for people with cognitive impairment.

(i) To develop a version of the revised Patients’ Attitude Towards Deprescribing (rPATD) questionnaire for people with mild cognitive impairment (MCI) and mild‐to‐moderate dementia (rPATDcog); and (ii) to capture the beliefs and attitudes of this population and their carers about deprescribing through a pilot study.

Teaching Geriatric Medicine in Vietnam: Introduction of an interactive learning module for medical students

Demand for health care for older people is increasing in South East Asia as the proportion of people aged older than 60 years increases [1]. An understanding of geriatric medicine is essential for provision of appropriate care, but in countries like Vietnam only 12.5% of medical schools have independent units for geriatric medicine [2]. Problem-based learning (PBL) and guided clinical experiences are recommended teaching styles for geriatric curricula [3,4]. Vietnamese medical courses tend to be traditional, didactic and focused on the biomedical model of patient care, although PBL has recently been introduced in some South-East Asian medical schools [5]. Partnership between Australia and Vietnam through the University of Sydney’s Hoc Mai Foundation previously introduced novel teaching methods for in-country postgraduate training in peri-natology [6].

Legacies of the Great War: Shell shock to delirium

During the centenary of World War I it is pertinent to examine the relationship between war, medicine and ageing. Literary works, like Remarque’s autobiographical novel and war poetry of the era, provide poignant insight into the ongoing medical and social issues arising from war. Writings by physicians, such as Freud, who sent two sons to war, and WHR Rivers, who treated soldiers with psychological sequelae, including three of the war poets, were to change the practice of psychiatry. Understanding gained from literary and medical writing at that time remains relevant to the care of sick older people, especially patients with delirium. Shell shock (with its nightmares and hallucinations) affected young men with normal brains, whereas delirium is a shell shock– like experience in frail old persons with vulnerable brains. Delirium, commonly caused by reversible intercurrent illness in patients with dementia, can be exacerbated by negative environmental and attitudinal factors. Insight acquired during the Great War into empathetic care of stress induced psychosis informs our holistic approach to the management of delirium today.