scholarly journals Anticholinergic burden in older adult inpatients: patterns from admission to discharge and associations with hospital outcomes

2021 ◽  
Vol 12 ◽  
pp. 204209862110125
Author(s):  
Maria Herrero-Zazo ◽  
Rachel Berry ◽  
Emma Bines ◽  
Debi Bhattacharya ◽  
Phyo K. Myint ◽  
...  
Keyword(s):  
Older Adults ◽  
Hospital Admission ◽  
Hospital Discharge ◽  
Geriatric Medicine ◽  
Prospective Trial ◽  
Adverse Outcomes ◽  
Prescribing Patterns ◽  
Plain Language ◽  
Post Discharge ◽  
Anticholinergic Medications

Background: Anticholinergic medications are associated with adverse outcomes in older adults and should be prescribed cautiously. We describe the Anticholinergic Risk Scale (ARS) scores of older inpatients and associations with outcomes. Methods: We included all emergency, first admissions of adults ⩾65 years old admitted to one hospital over 4 years. Demographics, discharge specialty, dementia/history of cognitive concern, illness acuity and medications were retrieved from electronic records. ARS scores were calculated as the sum of anticholinergic potential for each medication (0 = limited/none; 1 = moderate; 2 = strong and 3 = very strong). We categorised patients based on admission ARS score [ARS = 0 (reference); ARS = 1; ARS = 2; ARS ⩾ 3] and change in ARS score from admission to discharge [admission and discharge ARS = 0 (reference); same; decreased; increased]. We described anticholinergic prescribing patterns by discharge specialty and explored multivariable associations between ARS score categories and mortality using logistic regression [odds ratios (ORs), 95% confidence intervals (CIs)]. Results: From 33,360 patients, 10,183 (31%) were prescribed an anticholinergic medication on admission. Mean admission ARS scores were: Cardiology and Stroke = 0.56; General Medicine = 0.78; Geriatric Medicine = 0.83; Other medicine = 0.81; Trauma and Orthopaedics = 0.66; Other Surgery = 0.65. Mean ARS did not increase from admission to discharge in any specialty but reductions varied significantly, from 4.6% (Other Surgery) to 27.7% (Geriatric Medicine) ( p < 0.001). The odds of both 30-day inpatient and 30-day post-discharge mortality increased with admission ARS = 1 (OR = 1.21, 95% CI 1.01–1.44 and OR = 1.44, 1.18–1.74) but not with ARS = 2 or ARS ⩾ 3. The odds of 30-day post-discharge mortality were higher in all ARS change categories, relative to no anticholinergic exposure (same: OR = 1.45, 1.21–1.74, decreased: OR = 1.27, 1.01–1.57, increased: OR = 2.48, 1.98–3.08). Conclusion: The inconsistent dose–response associations with mortality may be due to confounding and measurement error which may be addressed by a prospective trial. Definitive evidence for this prevalent modifiable risk factor is required to support clinician behaviour-change, thus reducing variation in anticholinergic deprescribing by inpatient speciality. Plain language summary We describe how commonly medicines which block the chemical acetylcholine are prescribed to older adults admitted to hospital as an emergency and explore links between these medicines and death during or soon after hospital admission Backgroud: Medicines which block the chemical acetylcholine are commonly prescribed to treat symptoms such as itch and difficulty sleeping or to treat medical conditions such as depression. However, some studies in older adults have found potential links between these medicines and confusion and falls. Therefore, doctors are recommended to prescribe these drugs cautiously in adults aged 65 years and over. Methods: In our paper we use data collected as part of routine medical care at one university hospital to describe how often these medicines are prescribed in a large sample of older adults admitted to hospital as an emergency. We look at the medicines patients are prescribed on admission to the hospital and also when they are later discharged. Results: We find that these medicines are frequently prescribed. We also find that, in general, patients are prescribed fewer of these potentially harmful medicines on hospital discharge compared with hospital admission. This suggests that clinicians are aware of advice to prescribe acetylcholine blocking medicines cautiously and they are more often stopped in hospital than started. However, we find a lot of variation in practice depending on which hospital specialty was caring for the patient during their inpatient stay. We also find potential links with these medicines and death during the admission or soon after hospital discharge, but these potential links are not always consistent. Conclusion: Further study is needed to fully understand links between medicines that block acetylcholine and late life health. This will be important to reduce variation in prescribing practices.

scholarly journals The COVID-19 Pandemic Reignites the Need for Person-Centered Gerontological Approach

2021 ◽  
Vol 7 ◽  
pp. 233372142110418
Author(s):  
Pamela A. Saunders ◽  
Tara McMullen ◽  
Sonya Barsness ◽  
Andrew Carle ◽  
Gay Powell Hanna
Keyword(s):  
Older Adults ◽  
Policy Development ◽  
Geriatric Medicine ◽  
Adverse Outcomes ◽  
Call To Action ◽  
Person Centered Care ◽  
People With Dementia ◽  
Care Partners ◽  
National Response ◽  
Centered Care

The national response to the COVID-19 pandemic pressed gerontologists to reflect, redesign, and reform services supporting older adults. Efforts to isolate a peer cohort to stabilize and maintain a standard of health had adverse outcomes and added pressure conflicting with autonomy and individual desires. In this, person-centered care emerges as a meaningful archetype to address dignity and independence. This article presents views from academics and practitioners across an interdisciplinary spectrum, arising from a webinar hosted by Georgetown University Program in Aging & Health. A description of personhood as an extension of the humanities is followed by a robust discussion of safety and autonomy for older adults during the COVID-19 pandemic. We examine the necessary commute between critical gerontological theory and the practice of humanistic gerontology. Further, this article disentangles humanism and person-centered care to balance autonomy and safety for older adults in congregate living situations and focuses on specific populations: people with dementia and their care partners. Discussion on the importance of person-centered policy development in a public health pandemic is also explored. The article concludes with a call to action for the adoption of a comprehensive person-centered care model across the fields of gerontology and geriatric medicine.

Unexpected deaths and unplanned re-admissions in infants discharged home after cardiac surgery: a systematic review of potential risk factors

2014 ◽  
Vol 25 (5) ◽  
pp. 839-852 ◽  
Author(s):  
Jenifer Tregay ◽  
Jo Wray ◽  
Catherine Bull ◽  
Rodney C. Franklin ◽  
Piers Daubeney ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cardiac Surgery ◽  
Hospital Discharge ◽  
Care Pathway ◽  
Early Postoperative Period ◽  
Adverse Outcomes ◽  
Cochrane Library ◽  
Post Discharge ◽  
Feeding Difficulties ◽  
Wide Range

AbstractBackgroundBabies with CHDs are a particularly vulnerable population with significant mortality in their 1st year. Although most deaths occur in the hospital within the early postoperative period, around one-fifth of postoperative deaths in the 1st year of life may occur after hospital discharge in infants who have undergone apparently successful cardiac surgery.AimTo systematically review the published literature and identify risk factors for adverse outcomes, specifically deaths and unplanned re-admissions, following hospital discharge after infant surgery for life-threatening CHDs.MethodsA systematic search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Knowledge, and PsycINFO electronic databases, supplemented by manual searching of conference abstracts.ResultsA total of 15 studies were eligible for inclusion. Almost exclusively, studies were conducted in single US centres and focussed on children with complex single ventricle diagnoses. A wide range of risk factors were evaluated, and those more frequently identified as having a significant association with higher mortality or unplanned re-admission risk were non-Caucasian ethnicity, lower socio-economic status, co-morbid conditions, age at surgery, operative complexity and procedure type, and post-operative feeding difficulties.ConclusionsStudies investigating risk factors for adverse outcomes post-discharge following diverse congenital heart operations in infants are lacking. Further research is needed to systematically identify higher risk groups, and to develop interventions targeted at supporting the most vulnerable infants within an integrated primary and secondary care pathway.

scholarly journals AGE-FRIENDLY CARE AND MOBILITY IN HOSPITALIZED OLDER ADULTS WITH COGNITIVE IMPAIRMENT

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S446-S446
Author(s):  
Jasmine K Vickers ◽  
Richard E Kennedy ◽  
Shari Biswal ◽  
David James ◽  
Katrina Booth ◽  
...  
Keyword(s):  
Older Adults ◽  
Cognitive Impairment ◽  
Patient Outcomes ◽  
Medical Center ◽  
Academic Medical Center ◽  
Adverse Outcomes ◽  
Care Needs ◽  
Post Discharge ◽  
Before And After ◽  
Hospitalized Older Adults

Abstract Hospitalization of older adults with cognitive impairment (CI) has been associated with higher risk for adverse outcomes. Acute Care for Elders (ACE) Units were developed to meet the unique hospital care needs of older adults and have been associated with reductions in functional decline and readmissions. The Virtual ACE intervention was developed to disseminate ACE principles across hospital units. Virtual ACE included training interprofessional providers to utilize screens and care protocols to optimize care for older adults on eight units at a large academic medical center. We conducted a preliminary analysis of mobility and patient outcomes before and after Virtual ACE among 192 older adults with CI on hospital admission. Chi-Square tests were used to examine the associations between Virtual ACE and patient outcomes. There were statistically significant pre vs. post improvements in patients’ mobility from bed to chair (30% vs. 51%, p=0.011) and on the unit hallway (12% vs. 27%, p=0.046). Although not statistically significant, there were also improvements in hospital room mobility (39% vs. 50%, p=0.214) and documentation of activities of daily living (ADL) screens (70% vs. 80%, p=0.196). There were non-significant reductions in pressure ulcer prevalence (26% vs. 22%) and restraint use (5% vs. 0%) during the hospital stay. Pain was similar before and after Virtual ACE. Virtual ACE was associated with increased mobility and slight reductions in adverse outcomes. As increased hospital mobility improves patient functioning post-discharge, Virtual ACE has the potential to maintain function and enhance outcomes in hospitalized older adults with CI.

Prescribing Practices of Anticholinergic Medications and Their Association With Cognition in an Extended Care Setting

2010 ◽  
Vol 31 (2) ◽  
pp. 239-259 ◽  
Author(s):  
Lauren L. Drag ◽  
Sara L. Wright ◽  
Linas A. Bieliauskas
Keyword(s):  
Older Adults ◽  
Clinical Care ◽  
Care Center ◽  
Anticholinergic Drug ◽  
Prescribing Patterns ◽  
Prescribing Practices ◽  
Neuropsychological Battery ◽  
Cognitive Measures ◽  
Anticholinergic Medications ◽  
Extended Care

The current study examined prescribing patterns of anticholinergic (AC) medications and their association with cognitive function in 450 nondemented and nondelirious older adults hospitalized in a postacute extended care center. Participants completed a brief neuropsychological battery that included measures of general mental status, memory, judgment, and executive functioning as part of standard clinical care. An AC burden score was calculated for each participant based on medications taken the day of the testing using the Anticholinergic Drug Scale. Although use of AC medications was common, the majority of participants were taking medications with only minimal AC properties. AC burden and total number of AC medications were negatively correlated with age. AC burden was not associated with lower performance on any of the cognitive measures. In sum, current prescribing practices of AC medications are not associated with negative cognitive effects in a sample of older adults hospitalized in an extended care center.

scholarly journals Frailty status as a potential factor in increased postoperative opioid use in older adults

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Elizabeth D. Auckley ◽  
Nathalie Bentov ◽  
Shira Zelber-Sagi ◽  
Lily Jeong ◽  
May J. Reed ◽  
...  
Keyword(s):  
Older Adults ◽  
Hospital Discharge ◽  
Elective Surgery ◽  
Pain Catastrophizing ◽  
Well Being ◽  
Opioid Consumption ◽  
Opioid Use ◽  
Post Discharge ◽  
Opioid Prescription ◽  
Frailty Status

Abstract Background Prescription opioids are commonly used for postoperative pain relief in older adults, but have the potential for misuse. Both opioid side effects and uncontrolled pain have detrimental impacts. Frailty syndrome (reduced reserve in response to stressors), pain, and chronic opioid consumption are all complex phenomena that impair function, nutrition, psychologic well-being, and increase mortality, but links among these conditions in the acute postoperative setting have not been described. This study seeks to understand the relationship between frailty and patterns of postoperative opioid consumption in older adults. Methods Patients ≥ 65 years undergoing elective surgery with a planned hospital stay of at least one postoperative day were recruited for this cohort study at pre-anesthesia clinic visits. Preoperatively, frailty was assessed by Edmonton Frailty and Clinical Frailty Scales, pain was assessed by Visual Analog and Pain Catastrophizing Scales, and opioid consumption was recorded. On the day of surgery and subsequent hospitalization days, average pain ratings and total opioid consumption were recorded daily. Seven days after hospital discharge, patients were interviewed using uniform questionnaires to measure opioid prescription use and pain rating. Results One hundred seventeen patients (age 73.0 (IQR 67.0, 77.0), 64 % male), were evaluated preoperatively and 90 completed one-week post discharge follow-up. Preoperatively, patients with frailty were more likely than patients without frailty to use opioids (46.2 % vs. 20.9 %, p = 0.01). Doses of opioids prescribed at hospital discharge and the prescribed morphine milligram equivalents (MME) at discharge did not differ between groups. Seven days after discharge, the cumulative MME used were similar between cohorts. However, patients with frailty used a larger fraction of opioids prescribed to them (96.7 % (31.3, 100.0) vs. 25.0 % (0.0, 83.3), p = 0.007) and were more likely (OR 3.7, 95 % CI 1.13–12.13) to use 50 % and greater of opioids prescribed to them. Patients with frailty had higher pain scores before surgery and seven days after discharge compared to patients without frailty. Conclusions Patterns of postoperative opioid use after discharge were different between patients with and without frailty. Patients with frailty tended to use almost all the opioids prescribed while patients without frailty tended to use almost none of the opioids prescribed.

scholarly journals Risks associated with continuation of potentially inappropriate antihypertensive medications in older adults receiving hemodialysis

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Rasheeda K. Hall ◽  
Sarah Morton ◽  
Jonathan Wilson ◽  
Patti L. Ephraim ◽  
L. Ebony Boulware ◽  
...  
Keyword(s):  
Older Adults ◽  
Functional Limitations ◽  
Adverse Outcomes ◽  
Dialysis Initiation ◽  
Prescribing Patterns ◽  
Potentially Inappropriate Medications ◽  
Antihypertensive Medications ◽  
Risk Of Death ◽  
Increased Risk ◽  
Before And After

Abstract Background and objectives After dialysis initiation, older adults may experience orthostatic or post-dialysis hypotension. Some orthostasis-causing antihypertensives (i.e., central alpha agonists and alpha blockers), are considered potentially inappropriate medications (PIMs) for older adults because they carry more risk than benefit. We sought to (1) describe antihypertensive PIM prescribing patterns before and after dialysis initiation and (2) ascertain the potential risk of adverse outcomes when these medications are continued after dialysis initiation. Design, setting, participants, and measurements Using United States Renal Data System data, we evaluated monthly prevalence of antihypertensive PIM claims in the period before and after dialysis initiation among older adults aged ≥66 years initiating in-center hemodialysis in the US between 2013 and 2014. Patients with an antihypertensive PIM prescription at hemodialysis initiation and who survived for 120 days were classified as ‘continuers’ or ‘discontinuers’ based on presence or absence of a refill within the 120 days after initiation. We compared rates of hospitalization and risk of death across these groups from day 121 through 24 months after dialysis initiation. Results Our study included 30,760 total patients, of whom 5981 (19%) patients had an antihypertensive PIM claim at dialysis initiation and survived ≥120 days. Most [65% (n = 3920)] were continuers. Those who continued (versus discontinued) were more likely to be black race (26% versus 21%), have dual Medicare-Medicaid coverage (31% versus 27%), have more medications on average (12 versus 9) and have no functional limitations (84% versus 80%). Continuers experienced fewer all-cause hospitalizations and deaths, but neither were statistically significant after adjustment (Hospitalization: RR 0.93, 95% CI 0.86, 1.00; Death: HR 0.89, 95% CI: 0.78–1.02). Conclusions Nearly one in five older adults had an antihypertensive PIM at dialysis initiation. Among those who survived ≥120 days, continuation of an antihypertensive PIM was not associated with increased risk of all-cause hospitalization or mortality.

scholarly journals Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: A nationwide cohort study

PLoS Medicine ◽  
2021 ◽  
Vol 18 (9) ◽  
pp. e1003804
Author(s):  
Shoshana J. Herzig ◽  
Timothy S. Anderson ◽  
Yoojin Jung ◽  
Long Ngo ◽  
Dae H. Kim ◽  
...  
Keyword(s):  
Older Adults ◽  
Renal Failure ◽  
Acute Renal Failure ◽  
Cohort Study ◽  
Adverse Events ◽  
Hospital Discharge ◽  
Healthcare Utilization ◽  
Colonic Motility ◽  
Post Discharge ◽  
Propensity Matching

Background Although analgesics are initiated on hospital discharge in millions of adults each year, studies quantifying the risks of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) among older adults during this transition are limited. We sought to determine the incidence and risk of post-discharge adverse events among older adults with an opioid claim in the week after hospital discharge, compared to those with NSAID claims only. Methods and findings We performed a retrospective cohort study using a national sample of Medicare beneficiaries age 65 and older, hospitalized in the United States hospitals in 2016. We excluded beneficiaries admitted from or discharged to a facility. We derived a propensity score that included over 100 factors potentially related to the choice of analgesic, including demographics, diagnoses, surgeries, and medication coadministrations. Using 3:1 propensity matching, beneficiaries with an opioid claim in the week after hospital discharge (with or without NSAID claims) were matched to beneficiaries with an NSAID claim only. Primary outcomes included death, healthcare utilization (emergency department [ED] visits and rehospitalization), and a composite of known adverse effects of opioids or NSAIDs (fall/fracture, delirium, nausea/vomiting, complications of slowed colonic motility, acute renal failure, and gastritis/duodenitis) within 30 days of discharge. After 3:1 propensity matching, there were 13,385 beneficiaries in the opioid cohort and 4,677 in the NSAID cohort (mean age: 74 years, 57% female). Beneficiaries receiving opioids had a higher incidence of death (1.8% versus 1.1%; RR 1.7 [1.3 to 2.3], p < 0.001, number needed to harm [NNH] 125), healthcare utilization (19.0% versus 17.4%; RR 1.1 [1.02 to 1.2], p = 0.02, NNH 59), and any potential adverse effect (25.2% versus 21.3%; RR 1.2 [1.1 to 1.3], p < 0.001, NNH 26), compared to those with an NSAID claim only. Specifically, they had higher relative risk of fall/fracture (4.5% versus 3.4%; RR 1.3 [1.1 to 1.6], p = 0.002), nausea/vomiting (9.2% versus 7.3%; RR 1.3 [1.1 to 1.4], p < 0.001), and slowed colonic motility (8.0% versus 6.2%; RR 1.3 [1.1 to 1.4], p < 0.001). Risks of delirium, acute renal failure, and gastritis/duodenitis did not differ between groups. The main limitation of our study is the observational nature of the data and possibility of residual confounding. Conclusions Older adults filling an opioid prescription in the week after hospital discharge were at higher risk for mortality and other post-discharge adverse outcomes compared to those filling an NSAID prescription only.

scholarly journals The Role of Frailty in Predicting 3 and 6 Months Functional Decline in Hospitalized Older Adults: Findings from a Secondary Analysis

2021 ◽  
Vol 18 (13) ◽  
pp. 7126
Author(s):  
João Tavares ◽  
Pedro Sa-Couto ◽  
João Duarte Reis ◽  
Marie Boltz ◽  
Elizabeth Capezuti
Keyword(s):  
Older Adults ◽  
Frailty Index ◽  
Functional Decline ◽  
Secondary Analysis ◽  
Secondary Data ◽  
Binary Logistic Regression ◽  
Adverse Outcomes ◽  
Average Score ◽  
Post Discharge ◽  
Hospitalized Older Adults

Frailty represents one of the most relevant geriatric syndromes in the 21st century and is a predictor of adverse outcomes in hospitalized older adult, such as, functional decline (FD). This study aimed to examine if frailty, evaluated with the Frailty Index (FI), can predict FD during and after hospitalization (3 and 6 months). Secondary data analysis of a prospective cohort study of 101 hospitalized older adults was performed. The primary outcome was FD at discharge, 3 and 6 months. The FI was created from an original database using 40 health deficits. Functional decline models for each time-point were examined using a binary logistic regression. The prevalence of frailty was 57.4% with an average score of 0.25 (±0.11). Frail patients had significant and higher values for functional decline and social support for all time periods and more hospital readmission in the 3 month period. Multivariable regression analysis showed that FI was a predictor of functional decline at discharge (OR = 1.07, 95% CI = 1.02–1.14) and 3-month (OR = 1.05, 95% CI = 1.01–1.09) but not 6-month (OR = 1.03, 95% CI = 0.99–1.09) follow-up. Findings suggest that frailty at admission of hospitalized older adults can predict functional decline at discharge and 3 months post-discharge.

scholarly journals Long-Term Survival of Older Patients Hospitalized for COVID-19. Do Clinical Characteristics upon Admission Matter?

2021 ◽  
Vol 18 (20) ◽  
pp. 10671
Author(s):  
Michał Chojnicki ◽  
Agnieszka Neumann-Podczaska ◽  
Mikołaj Seostianin ◽  
Zofia Tomczak ◽  
Hamza Tariq ◽  
...  
Keyword(s):  
Older Adults ◽  
Hospital Admission ◽  
Functional Capacity ◽  
Functional Impairment ◽  
Older Patients ◽  
Post Discharge ◽  
Term Survival ◽  
Care Plans ◽  
Risk Of Death ◽  
Male Sex

Older adults are particularly susceptible to COVID-19 in terms of both disease severity and risk of death. To compare clinical differences between older COVID-19 hospitalized survivors and non-survivors, we investigated variables influencing mortality in all older adults with COVID-19 hospitalized in Poznań, Poland, through the end of June 2020 (n = 322). In-hospital, post-discharge, and overall 180-day mortality were analyzed. Functional capacity prior to COVID-19 diagnosis was also documented. The mean age of subjects was 77.5 ± 10.0 years; among them, 191 were females. Ninety-five (29.5%) died during their hospitalization and an additional 30 (9.3%) during the post-discharge period (up to 180 days from the hospital admission). In our study, male sex, severe cognitive impairment, underlying heart disease, anemia, and elevated plasma levels of IL-6 were independently associated with greater mortality during hospitalization. During the overall 180-day observation period (from the hospital admission), similar characteristics, excluding male sex and additionally functional impairment, were associated with increased mortality. During the post-discharge period, severe functional impairment remained the only determinant. Therefore, functional capacity prior to diagnosis should be considered when formulating comprehensive prognoses as well as care plans for older patients infected with SARS-CoV-2.

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