Yolanda Falcone

Prevalence of and factors associated with prolonged length of stay in older hospitalized medical patients.

To characterize elderly medical patients and identify factors associated with prolonged length of stay.

Health status, geriatric syndromes and prescription of oral anticoagulant therapy in elderly medical inpatients with atrial fibrillation.

The aim of the present study was to investigate the prevalence of geriatric syndromes among older medical inpatients with atrial fibrillation, and their association with use of vitamin K antagonists.

Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence

Atrial fibrillation is more frequent in older patients, who have a higher risk of cardioembolic stroke and thromboembolism. Oral anticoagulant therapy is the standard of treatment for stroke prevention; however, under-prescription is still very common in older patients. The reasons underlying this phenomenon have not been systematically investigated, and true contraindications only partially account for it. An intimate skepticism on the real benefit-risk balance of oral anticoagulant therapy in the oldest patients seems to derive from the fact that most studies supporting it were conducted decades ago and included younger patients, with overall better functional and clinical status. In this review we will focus on the main barriers to anticoagulant therapy prescription in older patients and summarize the available evidences on the efficacy and safety of vitamin K antagonists and direct oral anticoagulants in this population. The encouraging evidence of a higher net clinical benefit of direct oral anticoagulants compared with warfarin should hopefully widen the treatment options also for frail individuals, thereby allowing a greater number of patients to be treated according to current international guidelines.

Prevalence, predictors and clinical impact of potentially inappropriate prescriptions in hospital-discharged older patients: A prospective study: PIP outcomes

Potentially inappropriate prescriptions (PIP) have been highly reported in older patients, but few studies have investigated their association with adverse clinical outcomes. The present study aimed to evaluate the prevalence and predictors of PIP in hospital‐discharged older adults, and to explore the association of PIP with death and rehospitalization.

Indications, appropriateness and drug interactions of proton pump inhibitors prescribed at hospital discharge in older medical patients: Letter to the Editor - Research Studies

Proton pump inhibitors (PPI) are among the most commonly used drugs worldwide, representing a cornerstone in the treatment of acid peptic disease. Although PPI have an excellent safety profile, longterm suppression of gastric acid raises a number of problems, including gastroduodenal bacterial overgrowth and infections such as Clostridium difficile enteritis. Furthermore, chronic PPI use has been associated with increased risk of hip fractures, nutritional deficiencies and overall mortality. PPI have also potentially adverse drug–drug interactions (DDI), such as the possible reduction of clopidogrel efficacy in coronary heart disease and thyroxine malabsorption. Finally, PPI have been linked to hyponatremia, especially in association with selective serotonin reuptake inhibitors. Older patients are at greater risk of DDI because of polytherapy, and, consequently, of adverse drug reactions. We carried out a retrospective study to evaluate clinical indications for PPI, prevalence, and predictors of inappropriate prescription and DDI involving PPI among older inpatients. The study was carried out at Città della Salute e della Scienza, a university teaching hospital in Turin, Italy. Patients aged ≥65 years discharged from a geriatric ward and an internal medicine ward with a PPI prescription between January and December 2014 were enrolled. Medical history, primary and secondary diagnosis, and therapy at discharge were collected. A prescription was defined appropriate when it was in keeping with the Italian Medicines Agency notes 1 or 48, which regulate the prescription of these drugs in Italy. Note 48 indicates PPI for the treatment of gastroesophageal reflux disease, peptic ulcer, Helicobacter pylori eradication and other acid hypersecretory conditions (e.g. Zollinger– Ellison syndrome). Note 1 allows PPI prescription for preventing gastrointestinal bleeding during chronic non-steroidal anti-inflammatory drugs or acetylsalicylic acid (ASA) treatment in patients with at least one of the following: age ≥65 years, gastrointestinal bleeding or peptic ulcer history, or concomitant therapy with corticosteroids or anticoagulants. Potential DDI were assessed through the Micromedex database (Micromedex; Truven Health Analytics, see Supporting Information Reference S1 for database link), and defined as major (might be life-threatening and/or require medical intervention to prevent serious adverse effects) or moderate (might exacerbate the patient’s condition and/or require a change in therapy). Among 1786 patients discharged in the study period, 974 received a PPI prescription. The mean age was 80.0 ± 8 years, and 52.7% were women. The median length of stay was 9 days, and the mean number of drugs was 8 ± 3. The commonest indication for PPI (64.3%) was gastric protection during nonsteroidal anti-inflammatory drugs or ASA treatment, almost all (97.5%) patients were receiving the latter. In patients receiving ASA, 19% of prescriptions occurred in patients aged ≥80 years without a history of cardiovascular events. Less common indications for PPI included gastric ulcer (14.2%), gastroesophageal reflux disease (8.2%), duodenal ulcer (6.7%), reflux esophagitis (3.8%), eradication of Helicobacter pylori (2.2%) and other acid hypersecretory conditions (0.6%). Inappropriate PPI prescription was documented in 43.4% of patients. At least one potential major DDI was observed in 9% of patients, almost all involving citalopram and clopidogrel (48% and 46% of cases, respectively). At least one potential moderate DDI was found in 36% of patients; double or triple moderate DDI were found in 6.3% and 1.1% of patients, respectively. The most common drug involved was warfarin (31%), followed by digoxin (20%), levothyroxine (19%), alprazolam (11%) and iron (10%; for further details see Supporting Information Table S1). Demographic and clinical variables of patients and results of univariate analysis are reported in Table 1. After multivariate analysis, internal medicine ward discharge (OR 1.35, 95% CI 1.03–1.76), longer length of stay (OR 1.02, 95% CI 1.01–1.04) and the presence of moderate DDI (OR 1.75, 95% CI 1.33–2.30) were associated with a greater risk of inappropriate prescription, whereas older age (OR 0.98, 95% CI 0.97–0.99) and prescription of esomeprazole (OR 0.33, 95% CI 0.15–0.71) were associated with increased appropriateness. The present results, in keeping with other studies, confirm a high prevalence of inappropriate PPI prescription in the setting of a university teaching hospital. RESEARCH STUDIES Letters to the Editor

Informed Consent in Older Medical Inpatients: Assessment of Decision-Making Capacity

tion efforts worldwide. In Mexico, like in the United States, almost 50% of older adults have prediabetes mellitus. In the United States alone, each day since January 1, 2011, approximately 10,000 adults turned 65—an anticipated trend for the next 17 years. There is a need for intensified public health efforts by all countries addressing the unique national and individual burdens associated with diabetes mellitus management and prevention in older adults. This is a priority for the health system and for society. More resources need to be allocated to the design of new strategies to move from a treatment approach to one of prevention. In all countries, there is little or no intervention for the population with prediabetes mellitus. By shifting priorities, individuals’ catastrophic expenditures will decrease, and the high costs of temporary disability, permanent disability, and premature death that diabetes mellitus generates in older adults will diminish. New models and programs of care need to be implemented that can respond to the diverse health services that will be needed as a result of the epidemiological transition, particularly for diabetes mellitus and hypertension in older adults.

Prevalence and predictors of inappropriate prescribing according to the Screening Tool of Older People's Prescriptions and Screening Tool to Alert to Right Treatment version 2 criteria in older patients discharged from geriatric and internal medicine wards: A prospective observational multicenter study

To evaluate the prevalence and predictors of potentially inappropriate medications (PIM) and potential prescribing omissions (PPO) in hospital‐discharged older patients, according to the recently updated Screening Tool of Older Peoples Prescriptions and Screening Tool to Alert to Right Treatment version 2 criteria.

Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope

BACKGROUND Long QT and use of QT-prolonging drugs are common among older patients receiving polytherapies, but real-world evidence on their impact in clinical practice is controversial. We investigated prevalence, variables associated and clinical implications of prolonged corrected QT (QTc) among patients from the Syncope and Dementia study. METHODS Observational, prospective, multicenter study. Patients≥65 years with dementia and fall suspected for syncope in the previous three months were enrolled. Several clinical variables and the complete list of medications were recorded for each patient. A 12‑lead ECG was obtained and corrected QT was calculated by the Bazetts formula. One-year followup for death and recurrent syncope was performed. RESULTS Prolonged QTc was observed in 25% of the 432 enrolled patients (mean age 83.3), and was significantly associated with male gender (OR 2.09; 95% CI 1.34-3.26) and diuretics use (OR 1.85; 95% CI 1.18-2.90). At one-year 23.3% of patients died and 30.4% reported at least one recurrent event. Variables associated with one-year mortality were: age, male gender, atrial fibrillation (AF), use of calcium channel blockers and prolonged QTc (OR 1.80; 95% CI 1.01-3.20). Among patients with prolonged QTc a significant interaction for mortality was found with AF. Recurrent events were associated with the use of antiplatelets, cholinesterase. inhibitors and antipsychotics, but not with prolonged QTc. CONCLUSIONS We documented a high prevalence of prolonged QTc, that was associated with male gender and diuretics but not with psychoactive medications. Patients with prolonged QTc had higher one-year mortality, that was four-fold increased in those with concomitant AF.