Search

Background: End‐of‐life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age. Methods: We conducted a cross‐sectional study of a 20% sample of Medicare fee‐for‐service beneficiaries aged ≥66 years who died in 2016–2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary‐level outcomes by physician age (<40, 40–49, 50–59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high‐intensity care at the EOL. Results: Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40–49, 50–59, and ≥60, respectively; p‐for‐trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p‐for‐trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p‐for‐trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p‐for‐trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p‐for‐trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p‐for‐trend <0.001) in the last 30 days of life, and in‐hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p‐for‐trend <0.001). Conclusions: We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education. [ABSTRACT FROM AUTHOR]

Background: People living with dementia (PLWD) have complex medication regimens, exposing them to increased risk of harm. Pragmatic deprescribing strategies that align with patient‐care partner goals are needed. Methods: A pilot study of a pharmacist‐led intervention to optimize medications with patient‐care partner priorities, ran May 2021–2022 at two health systems. PLWD with ≥7 medications in primary care and a care partner were enrolled. After an introductory mailing, dyads were randomized to a pharmacist telehealth intervention immediately (intervention) or delayed by 3 months (control). Feasibility outcomes were enrollment, intervention completion, pharmacist time, and primary care provider (PCP) acceptance of recommendations. To refine pragmatic data collection protocols, we assessed the Medication Regimen Complexity Index (MRCI; primary efficacy outcome) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS). Results: 69 dyads enrolled; 27 of 34 (79%) randomized to intervention and 28 of 35 (80%) randomized to control completed the intervention. Most visits (93%) took more than 20 min and required multiple follow‐up interactions (62%). PCPs responded to 82% of the pharmacists' first messages and agreed with 98% of recommendations. At 3 months, 22 (81%) patients in the intervention and 14 (50%) in the control had ≥1 medication discontinued; 21 (78%) and 12 (43%), respectively, had ≥1 new medication added. The mean number of medications decreased by 0.6 (3.4) in the intervention and 0.2 (1.7) in the control, reflecting a non‐clinically meaningful 1.0 (±12.4) point reduction in the MRCI among intervention patients and a 1.2 (±12.9) point increase among control. FCMAHS scores decreased by 3.3 (±18.8) points in the intervention and 2.5 (±14.4) points in the control. Conclusion: Though complex, pharmacist‐led telehealth deprescribing is feasible and may reduce medication burden in PLWD. To align with patient‐care partner goals, pharmacists recommended deprescribing and prescribing. If scalable, such interventions may optimize goal‐concordant care for PLWD. See related Editorial by Pickering and Anderson. [ABSTRACT FROM AUTHOR]

Background: The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence‐informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale‐up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub‐and‐spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub‐and‐spoke model without cost to PIM reduction or site engagement. Methods: We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12‐month baseline to 12‐month post‐implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation. Results: The proportion of PIMs at all four sites declined significantly from pre‐ to post‐EQUIPPED: at traditional site 1 from 8.9% (8.1–9.6) to 3.6% (3.6–9.6) (p < 0.001); at spread site 1 from 12.2% (11.2–13.2) to 7.1% (6.1–8.1) (p < 0.001); at spread site 2 from 11.3% (10.1–12.6) to 7.9% (6.4–8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9–17.4) to 11.7% (10.3–13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites. Conclusions: EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID‐19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real‐world conditions. The hub‐and‐spoke model offers an effective way to scale‐up EQUIPPED though a speed or quality advantage could not be shown. [ABSTRACT FROM AUTHOR]

Background: Prescribing cascades are important contributors to polypharmacy. Little is known about which older adults are at highest risk of experiencing prescribing cascades. We explored which older veterans are at highest risk of the gabapentinoid (including gabapentin and pregabalin)–loop diuretic (LD) cascade, given the dramatic increase in gabapentinoid prescribing in recent years. Methods: Using Veterans Affairs and Medicare claims data (2010–2019), we performed a prescription sequence symmetry analysis (PSSA) to assess loop diuretic initiation before and after gabapentinoid initiation among older veterans (≥66 years). To identify the cascade, we calculated the adjusted sequence ratio (aSR), which assesses the temporality of LD relative to gabapentinoid initiation. To explore high‐risk groups, we used multivariable logistic regression with prescribing order modeled as a binary dependent variable. We calculated adjusted odds ratios (aORs), measuring the extent to which factors are associated with one prescribing order versus another. Results: Of 151,442 veterans who initiated a gabapentinoid, there were 1,981 patients who initiated a LD within 6 months after initiating a gabapentinoid compared to 1,599 patients who initiated a LD within 6 months before initiating a gabapentinoid. In the gabapentinoid–LD group, the mean age was 73 years, 98% were male, 13% were Black, 5% were Hispanic, and 80% were White. Patients in each group were similar across patient and health utilization factors (standardized mean difference <0.10 for all comparisons). The aSR was 1.23 (95% CI: 1.13, 1.34), strongly suggesting the cascade's presence. People age ≥85 years were less likely to have the cascade (compared to 66–74 years; aOR 0.74, 95% CI: 0.56–0.96), and people taking ≥10 medications were more likely to have the cascade (compared to 0–4 drugs; aOR 1.39, 95% CI: 1.07–1.82). Conclusions: Among older adults, those who are younger and taking many medications may be at higher risk of the gabapentinoid–LD cascade, contributing to worsening polypharmacy and potential drug‐related harms. We did not identify strong predictors of this cascade, suggesting that prescribing cascade prevention efforts should be widespread rather than focused on specific subgroups. [ABSTRACT FROM AUTHOR]

Background: High‐risk medications like benzodiazepines, sedative hypnotics, and antipsychotics are commonly prescribed for hospitalized older adults, despite guidelines recommending avoidance. Prior interventions have not fully addressed how physicians make such prescribing decisions, particularly when experiencing stress or cognitive overload. Simulation training may help improve prescribing decision‐making but has not been evaluated for overprescribing. Methods: In this two‐arm pragmatic trial, we randomized 40 first‐year medical resident physicians (i.e., interns) on inpatient general medicine services at an academic medical center to either intervention (a 40‐minute immersive simulation training) or control (online educational training) groups. The primary outcome was the number of new benzodiazepine, sedative hypnotic, or antipsychotic orders for treatment‐naïve older adults during hospitalization. Secondary outcomes included the same outcome by all providers, being discharged on one of the medications, and orders for related or control medications. Outcomes were measured using electronic health record data over each intern's service period (~2 weeks). Outcomes were evaluated using generalized estimating equations, adjusting for clustering. Results: In total, 522 treatment‐naïve older adult patients were included in analyses. Over follow‐up, interns prescribed ≥1 high‐risk medication for 13 (4.9%) intervention patients and 13 (5.0%) control patients. The intervention led to no difference in the number of new prescriptions (Rate Ratio [RR]: 0.85, 95%CI: 0.31–2.35) versus control and no difference in secondary outcomes. In secondary analyses, intervention interns wrote significantly fewer "as‐needed" ("PRN") order types for the high‐risk medications (RR: 0.29, 95%CI: 0.08–0.99), and instead tended to write more "one‐time" orders than control interns, though this difference was not statistically significant (RR: 2.20, 95%CI: 0.60–7.99). Conclusions: Although this simulation intervention did not impact total high‐risk prescribing for hospitalized older adults, it did influence how the interns prescribed, resulting in fewer PRN orders, suggesting possibly greater ownership of care. Future interventions should consider this insight and implementation lessons raised. Trial Registration: Clinicaltrials.gov(NCT04668248). [ABSTRACT FROM AUTHOR]

Background: Evaluating infection in home‐based primary care is challenging, and these challenges may impact antibiotic prescribing. A refined understanding of antibiotic decision‐making in this setting can inform strategies to promote antibiotic stewardship. This study investigated antibiotic decision‐making by exploring the perspectives of clinicians in home‐based primary care. Methods: Clinicians from the Department of Veterans Affairs Home‐Based Primary Care Program were recruited. Semi‐structured interviews were conducted from June 2022 through September 2022 using a discussion guide. Transcripts were analyzed using grounded theory. The constant comparative method was used to develop a coding structure and to identify themes. Results: Theoretical saturation was reached after 22 clinicians (physicians, n = 7; physician assistants, n = 2, advanced practice registered nurses, n = 13) from 19 programs were interviewed. Mean age was 48.5 ± 9.3 years, 91% were female, and 59% had ≥6 years of experience in home‐based primary care. Participants reported uncertainty about the diagnosis of infection due to the characteristics of homebound patients (atypical presentations of disease, presence of multiple chronic conditions, presence of cognitive impairment) and the challenges of delivering medical care in the home (limited access to diagnostic testing, suboptimal quality of microbiological specimens, barriers to establishing remote access to the electronic health record). When faced with diagnostic uncertainty about infection, participants described many factors that influenced the decision to prescribe antibiotics, including those that promoted prescribing (desire to avoid hospitalization, pressure from caregivers, unreliable plans for follow‐up) and those that inhibited prescribing (perceptions of antibiotic‐associated harms, willingness to trial non‐pharmacological interventions first, presence of caregivers who were trusted by clinicians to monitor symptoms). Conclusions: Clinicians face the difficult task of balancing diagnostic uncertainty with many competing considerations during the treatment of infection in home‐based primary care. Recognizing these issues provides insight into strategies to promote antibiotic stewardship in home care settings. [ABSTRACT FROM AUTHOR]

Background: Adverse drug events (ADEs) during hospitalization are a serious, yet preventable concern for older adults. Our institution designed a Geriatric Prescribing Context (GPC) to adjust doses for the older adult population but its impact on ADEs was unknown. The goal of this study was to assess any differences in rates of ADEs before and after its implementation in July 2017. Methods: We used relevant ICD‐10 codes followed by confirmatory chart review to identify dose‐related ADEs from 10 commonly used medications at our institution. We assessed differences in the number of admissions with an ADE before and after the GPC implementation using a test of binomial proportions. The pre‐period was from July 2016 through June 2017 and the post‐period was from August 2017 through July 2018. We compared the rate of ADEs per 1000 patient days between periods with a Poisson rate test and further examined any differences in harm categories using a Fisher's exact test. Results: The proportion of admissions with any dose‐related ADEs significantly decreased from 0.0082 to 0.0037 after the GPC (p = 0.04). The rate of dose‐related ADEs also declined from 2.5 per 1000 patient days to 1.1 per 1000 patient days (p = 0.001). Harm categories did not change significantly between time points (p = 0.30). Conclusions: Based on our list of relevant ICD‐10 codes, the GPC was associated with lower dose‐related ADEs for our selected medications among hospitalized older adults. [ABSTRACT FROM AUTHOR]

Improving the quality of medication use and medication safety are important priorities for healthcare providers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2022. We selected high‐quality studies from an OVID search and hand searching of major high impact journals that advanced the field of research forward. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The MedSafer Study, a cluster randomized clinical trial in Canada, evaluated whether patient specific deprescribing reports generated by electronic decision support software resulted in reduced adverse drug events in the 30 days post hospital discharge in older adults (domain: deprescribing). The second study, a retrospective cohort study using data from Premier Healthcare Database, examined in‐hospital adverse clinical events associated with perioperative gabapentin use among older adults undergoing major surgery (domain: medication safety). The third study used an open‐label parallel controlled trial in 39 Australian aged‐care facilities to examine the effectiveness of a pharmacist‐led intervention to reduce medication‐induced deterioration and adverse reactions (domain: optimizing medication use). Lastly, the fourth study engaged experts in a Delphi method process to develop a consensus list of clinically important prescribing cascades that adversely affect older persons' health to aid clinicians to identify, prevent, and manage prescribing cascades (domain: optimizing medication use). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens. [ABSTRACT FROM AUTHOR]

The article discusses an analysis of the Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) implementation trial to determine trends in gabapentinoid prescribing among U.S. Veterans Affairns (VA) emergency departments (ED) implementing the program. Cited are a comparison of gabapentinoid prescribing during the pre- and post-implementation periods in the dashboard and academic detailing groups, and limitations of the study.

Deprescribing is the intentional dose reduction or discontinuation of a medication. The development of deprescribing interventions should take into consideration important organizational, interprofessional, and patient‐specific barriers that can be further complicated by the presence of multiple prescribers involved in a patient's care. Patients who receive care from an increasing number of prescribers may experience disruptions in the timely transfer of relevant healthcare information, increasing the risk of exposure to drug–drug interactions and other medication‐related problems. Furthermore, the fragmentation of healthcare information across health systems can contribute to the refilling of discontinued medications, reducing the effectiveness of deprescribing interventions. Thus, deprescribing interventions must carefully consider the unique characteristics of patients and their prescribers to ensure interventions are successfully implemented. In this special article, an international working group of physicians, pharmacists, nurses, epidemiologists, and researchers from the United States Deprescribing Research Network (USDeN) developed a socioecological model to understand how multiple prescribers may influence the implementation of a deprescribing intervention at the individual, interpersonal, organizational, and societal level. This manuscript also includes a description of the concept of multiple prescribers and outlines a research agenda for future investigations to consider. The information contained in this manuscript should be used as a framework for future deprescribing interventions to carefully consider how multiple prescribers can influence the successful implementation of the service and ensure the intervention is as effective as possible. [ABSTRACT FROM AUTHOR]

Background: The Drug Burden Index (DBI) measures an individual's total exposure to anticholinergic and sedative medications. This systematic review aimed to investigate the association of the DBI with clinical and prescribing outcomes in observational pharmaco‐epidemiological studies, and the effect of DBI exposure on functional outcomes in pre‐clinical models. Methods: A systematic search of nine electronic databases, citation indexes and gray literature was performed (April 1, 2007–December 31, 2022). Studies that reported primary data on the association of the DBI with clinical or prescribing outcomes conducted in any setting in humans aged ≥18 years or animals were included. Quality assessment was performed using the Joanna Briggs Institute critical appraisal tools and the Systematic Review Centre for Laboratory animal Experimentation risk of bias tool. Results: Of 2382 studies screened, 70 met the inclusion criteria (65 in humans, five in animals). In humans, outcomes reported included function (n = 56), cognition (n = 20), falls (n = 14), frailty (n = 7), mortality (n = 9), quality of life (n = 8), hospitalization (n = 7), length of stay (n = 5), readmission (n = 1), other clinical outcomes (n = 15) and prescribing outcomes (n = 2). A higher DBI was significantly associated with increased falls (11/14, 71%), poorer function (31/56, 55%), and cognition (11/20, 55%) related outcomes. Narrative synthesis was used due to significant heterogeneity in the study population, setting, study type, definition of DBI, and outcome measures. Results could not be pooled due to heterogeneity. In animals, outcomes reported included function (n = 18), frailty (n = 2), and mortality (n = 1). In pre‐clinical studies, a higher DBI caused poorer function and frailty. Conclusions: A higher DBI may be associated with an increased risk of falls and decreased function and cognition. Higher DBI was inconsistently associated with increased mortality, length of stay, frailty, hospitalization or reduced quality of life. Human observational findings with respect to functional outcomes are supported by preclinical interventional studies. The DBI may be used as a tool to identify older adults at higher risk of harm. [ABSTRACT FROM AUTHOR]

Background: Prescribing cascades occur when a drug adverse event is misinterpreted as a new medical condition and a second, potentially unnecessary drug, is prescribed to treat the adverse event. The population‐level consequences of prescribing cascades remain unknown. Methods: This population‐based cohort study used linked health administrative databases in Ontario, Canada. The study included community‐dwelling adults, 66 years of age or older with hypertension and no history of heart failure (HF) or diuretic use in the prior year, newly dispensed a calcium channel blocker (CCB). Individuals subsequently dispensed a diuretic within 90 days of incident CCB dispensing were classified as the prescribing cascade group, and compared to those not dispensed a diuretic, classified as the non‐prescribing cascade group. Those with and without a prescribing cascade were matched one‐to‐one on the propensity score and sex. The primary outcome was a serious adverse event (SAE), which was the composite of emergency room visits and hospitalizations in the 90‐day follow‐up period. We estimated hazard ratios (HRs) with 95% confidence intervals (CI) for SAE using an Andersen–Gill recurrent events regression model. Results: Among 39,347 older adults with hypertension and no history of HF who were newly dispensed a CCB, 1881 (4.8%) had a new diuretic dispensed within 90 days after CCB initiation. Compared to the non‐prescribing cascade group, those in the prescribing cascade group had higher rates of SAEs (HR: 1.21, 95% CI: 1.02–1.43). Conclusions: The CCB‐diuretic prescribing cascade was associated with an increased rate of SAEs, suggesting harm beyond prescribing a second drug therapy. Our study raises awareness of the downstream impact of the CCB‐diuretic prescribing cascade at a population level and provides an opportunity for clinicians who identify this prescribing cascade to review their patients' medications to determine if they can be optimized. [ABSTRACT FROM AUTHOR]

Background: Potentially inappropriate medications (PIMs) in older adults are medications in which risks often outweigh benefits and are suggested to be avoided. Worldwide, many distinct guidelines and tools classify PIMs in older adults. Collating these guidelines and tools, mapping them to a medication classification system, and creating a crosswalk will enhance the utility of PIM guidance for research and clinical practice. Methods: We used the Anatomical Therapeutic Chemical (ATC) Classification System, a hierarchical classification system, to map PIMs from eight distinct guidelines and tools (2019 Beers Criteria, Screening Tool for Older Person's Appropriate Prescriptions [STOPP], STOPP‐Japan, German PRISCUS, European Union‐7 Potentially Inappropriate Medication [PIM] list, Centers for Medicare & Medicaid Services [CMS] High‐Risk Medication, Anticholinergic Burden Scale, and Drug Burden Index). Each PIM was mapped to ATC Level 5 (drug) and to ATC Level 4 (drug class). We then used the crosswalk (1) to compare PIMs and PIM drug classes across guidelines and tools to determine the number of PIMs that were index (drug‐induced adverse event) or marker (treatment of drug‐induced adverse event) drug of prescribing cascades, and (2) estimate the prevalence of PIM use in older adults continuously enrolled with fee‐for‐service Medicare in 2018 as use cases. Data visualization and descriptive statistics were used to assess guidelines and tools for both use cases. Results: Out of 480 unique PIMs identified, only three medications—amitriptyline, clomipramine, and imipramine and two drug classes—N06AA (tricyclic antidepressants) and N06AB (selective serotonin reuptake inhibitors), were noted in all eight guidelines and tools. Using the crosswalk, 50% of classes of index drugs and 47% of classes of marker drugs of known prescribing cascades were PIMs. Additionally, 88% of Medicare beneficiaries were dispensed ≥1 PIM across the eight guidelines and tools. Conclusion: We created a crosswalk of eight PIM guidelines and tools to the ATC classification system and created two use cases. Our findings could be used to expand the ease of PIM identification and harmonization for research and clinical practice purposes. [ABSTRACT FROM AUTHOR]

This editorial comments on the article by Hanlon et al. in this issue. [ABSTRACT FROM AUTHOR]

Reducing adverse drug events among older adults in heterogeneous and often chaotic emergency department (ED) settings requires a multidisciplinary approach. Recent research evaluates the impact of multicomponent protocols designed to reduce ED physician prescribing of potentially inappropriate medications (PIMs), including transdisciplinary training and leveraging electronic health records to provide real‐time alternative safer pharmaceuticals while providing personalized feedback to prescribers. Most new research is not randomized trial data. Although this current research does not consistently demonstrate a reduction in the prescribing of PIMs, these studies provide a foundation for emergency medicine healthcare teams, geriatricians, and pharmacists to collaborate with health informatics to continue advancing the frontiers of safer medication prescribing during episodes of acute care. [ABSTRACT FROM AUTHOR]

See the Reply by Semla et al. in this issue. [ABSTRACT FROM AUTHOR]

This article comments on the article by Rochon et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: In multimorbid older patients with type 2 diabetes mellitus (T2DM), the intensity of glucose‐lowering medication (GLM) should be focused on attaining a suitable level of glycated hemoglobin (HbA1c) while avoiding side effects. We aimed at identifying patients with overtreatment of T2DM as well as associated risk factors. Methods: In a secondary analysis of a multicenter study of multimorbid older patients, we evaluated HbA1c levels among patients with T2DM. Patients were aged ≥70 years, with multimorbidity (≥3 chronic diagnoses) and polypharmacy (≥5 chronic medications), enrolled in four university medical centers across Europe (Belgium, Ireland, Netherlands, and Switzerland). We defined overtreatment as HbA1c < 7.5% with ≥1 GLM other than metformin, as suggested by Choosing Wisely and used prevalence ratios (PRs) to evaluate risk factors of overtreatment in age‐ and sex‐adjusted analyses. Results: Among the 564 patients with T2DM (median age 78 years, 39% women), mean ± standard deviation HbA1c was 7.2 ± 1.2%. Metformin (prevalence 51%) was the most frequently prescribed GLM and 199 (35%) patients were overtreated. The presence of severe renal impairment (PR 1.36, 1.21–1.53) and outpatient physician (other than general practitioner [GP], i.e. specialist) or emergency department visits (PR 1.22, 1.03–1.46 for 1–2 visits, and PR 1.35, 1.19–1.54 for ≥3 visits versus no visits) were associated with overtreatment. These factors remained associated with overtreatment in multivariable analyses. Conclusions: In this multicountry study of multimorbid older patients with T2DM, more than one third were overtreated, highlighting the high prevalence of this problem. Careful balancing of benefits and risks in the choice of GLM may improve patient care, especially in the context of comorbidities such as severe renal impairment, and frequent non‐GP healthcare contacts. [ABSTRACT FROM AUTHOR]

The article presents a study which examined rates of overtreatment and deprescribing of antihyperglycemics at urban long-term care (LTC) facilities in British Columbia. Topics include data extracted for all residents, baseline characteristics of cohort, and results which suggest that overtreatment of type 2 diabetes (T2DM) continues to occur in LTC.

Background: Sodium‐glucose cotransporter‐2 inhibitor (SGLT2I) use has increased among community‐dwelling populations, but little is known about how clinicians have prescribed them for US nursing home (NH) residents. We described the adoption of SGLT2Is by prescribers caring for long‐stay NH residents by clinician specialty and over time, compared with sulfonylureas, an older diabetes medication class. Methods: We conducted a retrospective cohort study of prescribers of SGLT2Is and sulfonylureas for all long‐stay US NH residents aged 65 years or older (2017–2019). Using 100% of Medicare Part D claims linked to prescriber characteristics data, we identified all dispensings of SGLT2Is and sulfonylureas for long‐stay NH residents and their associated prescribers. We described the distribution of prescriber specialties for each drug class over time as well as the number of NH residents prescribed SGLT2s versus sulfonylureas. We estimated the proportions of prescribers who prescribed both drug classes versus only sulfonylureas or only SGLT2Is. Results: We identified 36,427 unique prescribers (SGLT2I: N = 5811; sulfonylureas: N = 35,443) for 117,667 NH residents between 2017 and 2019. For both classes, family medicine and internal medicine physicians accounted for most prescriptions (75%–81%). Most clinicians (87%) prescribed only sulfonylureas, 2% prescribed SGLT2Is only, and 11% prescribed both. Geriatricians were least likely to prescribe only SGLT2Is. We observed an increase in the number of residents with SGLT2I use from n = 2344 in 2017 to n = 5748 in 2019. Conclusions: Among NH residents, most clinicians have not incorporated SGLT2Is into their prescribing for diabetes, but the extent of use is increasing. Family medicine and internal medicine physicians prescribed the majority of diabetes medications for NH residents, and geriatricians were the least likely to prescribe only SGLT2Is. Future research should explore provider concerns regarding SGLT2I prescribing, particularly adverse events. [ABSTRACT FROM AUTHOR]

Background: Benzodiazepine and antipsychotic medications are routinely prescribed for symptom management in hospice patients, but have significant risks for older adults. We explored the extent to which patient and hospice agency characteristics are associated with variations in their prescribing. Methods: Cross‐sectional analysis of hospice‐enrolled Medicare beneficiaries aged ≥65 years in 2017 (N = 1,393,622 in 4219 hospice agencies). The main outcome was the hospice agency‐level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles. Rate ratios were used to compare the agencies with the highest and lowest prescription across patient and agency characteristics. Results: In 2017, hospice agency prescribing rates varied widely: for benzodiazepines, from a median of 11.9% (IQR 5.9,22.2) in the lowest‐prescribing quintile to 80.0% (IQR 76.9,84.2) in the highest‐prescribing quintile; for antipsychotics, it ranged from 5.5% (IQR 2.9,7.7) in the lowest to 63.9% (IQR 56.1,72.0) in the highest. Among the highest benzodiazepine‐ and antipsychotic‐ prescribing hospice agencies, there was a smaller proportion of patients from minoritized populations (benzodiazepine: non‐Hispanic Black rate ratio [RR] [Q5/Q1] 0.7, 95% CI 0.6–0.7, Hispanic RR 0.4, 95% CI 0.3–0.5; antipsychotic: non‐Hispanic Black RR 0.7, 95% CI 0.6–0.8, Hispanic RR 0.4, 95% CI 0.3–0.5). A greater proportion of rural beneficiaries were in the highest benzodiazepine‐prescribing quintile (RR 1.3, 95% CI 1.2–1.4), whereas this relationship was not present for antipsychotics. Larger hospice agencies were over‐represented in the highest prescribing quintile for both benzodiazepines (RR 2.6, 95% CI 2.5–2.7) and antipsychotics (RR 2.7, 95% CI 2.6–2.8), as were for‐profit agencies (benzodiazepine: RR 2.4, 95% CI 2.3–2.4; antipsychotic: RR 2.3, 95% CI 2.2–2.4). Prescribing rates varied widely across Census regions. Conclusions: Prescribing in hospice settings varies markedly across factors other than the clinical characteristics of enrolled patients. [ABSTRACT FROM AUTHOR]

Background: Published guidelines recommend high‐intensity statins following an ischemic stroke or transient ischemic attack (TIA). The authors examined the potential for disparate patterns of statin prescribing in a cluster randomized trial of transitional care following acute stroke or TIA. Methods: Medications taken before hospitalization and statins prescribed at discharge among stroke and TIA patients at 27 participating hospitals were examined. Any statin and intensive statin prescribed at discharge were compared by age (<65, 65–75, >75 years), racial category (White vs. Black), sex (male vs. female), and rurality (urban vs. non‐urban) using logistic mixed models. Results: Among 3211 patients (mean age 67 years; 47% female; 29% Black), 90% and 55%, respectively, were prescribed any statin or intensive statin therapy at discharge. White (vs. Black) patients (0.71, 0.51–0.98) less commonly received any statin prescription, while stroke (vs. TIA) patients (1.90, 1.38–2.62) and those residing in urban areas (1.66, 1.07–2.55) more commonly received any statin prescription. Among those prescribed a statin, only 42% of White and 51% of Black patients >75 years. were prescribed an intensive statin; the OR for intensive statin prescribing was 0.44 for patients >75 years and was similar in a subgroup not on a statin previously. Conclusion/Relevance: Following stroke or TIA, statin prescribing remains lower in White patients, in those with TIA, and in those in non‐urban areas. Intensive statin prescribing remains limited, particularly in patients >75 years. These data may inform efforts to improve guideline concordant prescribing for post‐stroke patients. [ABSTRACT FROM AUTHOR]

The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults is widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a regular cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2023 update, an interprofessional expert panel reviewed the evidence published since the last update (2019) and based on a structured assessment process approved a number of important changes including the addition of new criteria, modification of existing criteria, and formatting changes to enhance usability. The criteria are intended to be applied to adults 65 years old and older in all ambulatory, acute, and institutionalized settings of care, except hospice and end‐of‐life care settings. Although the AGS Beers Criteria® may be used internationally, it is specifically designed for use in the United States and there may be additional considerations for certain drugs in specific countries. Whenever and wherever used, the AGS Beers Criteria® should be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision‐making. [ABSTRACT FROM AUTHOR]

Background: Nursing home quality of care is a persistent challenge, with recent reports calling for increased reforms to improve quality and safety. Less is known about the clinical approaches currently used and the barriers perceived by skilled nursing facilities (SNFs) to provide care for their short‐stay residents. Methods: We conducted a nationally representative survey of SNFs from October 2020 to May 2021 to understand their care delivery approaches and perceived barriers. Our primary outcomes were the reported number of 23 separate care delivery approaches and the reported number of 12 separate barriers to reduce spending or improve care for SNF short‐stay residents. We also performed stratified analyses by facility participation in bundled payments and other SNF characteristics. Results: We received 377 responses from 693 SNFs contacted (response rate = 54%). SNFs reported an average of 16.8 care delivery approaches and an average of 5.0 barriers. While there were some differences observed in SNF characteristics, such as by bundled payments participation or ownership type, there were common care delivery approaches and barriers shared by most facilities. Care management practices, including reviewing the patient census and medication reconciliation on discharge, were the most common delivery approaches reported. SNFs were less likely to ensure the completion of a follow‐up appointment with a primary care provider or track repeat emergency room visits. Issues concerning staffing, such as staff turnover and/or burnout, and lack of resources to provide patients social support, mental health, and substance use services, were the most cited barriers to care delivery. Conclusions: Nationally, SNFs implemented a wide array of care delivery approaches, but challenges with staffing and limited resources to address patients' social and mental health needs were dominant. Individual SNFs may have limited ability to address these key barriers, so the involvement of many stakeholders across the entire healthcare system may be necessary. [ABSTRACT FROM AUTHOR]

See the related comment by Fauchon et al. [ABSTRACT FROM AUTHOR]

See the Reply by Candon et al. [ABSTRACT FROM AUTHOR]

In the article, the author presents their study which assessed the reduction of poly-central nervous system (CNS) medications in older people in an integrated healthcare system in the U.S. in 2018-2020. Also cited are the association between multiple CNS medications and the risks of falls and delirium, and the efforts by the Kaiser Permanente Southern California (KPSC) healthcare system to limit the use of poly-CNS drugs in older adults.

See related article by Wastila et al. in this issue. [ABSTRACT FROM AUTHOR]

The article discusses research which assessed interprofessional learner perceptions of a brief educational intervention tailored for opioid prescribing in older adults. The study evaluated pre- and post-intervention knowledge and confidence in medication safety and non-opioid treatment strategies. Findings revealed potential improvement of communication between providers and patients or their caregivers, as well as opportunity to educate caregivers and other providers.

The article suggests improvements for the value assessment of deprescribing interventions to reduce potentially inappropriate medications. It outlines limitations to current practice of deprescribing cost-effectiveness analyses (CEA) and recommendations for improvement including application of longer time horizon for deprescribing CEAs, tailoring deprescribing CEAs to the needs of decision makers, and adding patient-centric value elements.

Background: We characterized real‐world prescribing patterns of opioids and benzodiazepines (BZDs) for older adults to explore potential disparities by race and sex and to characterize patterns of co‐prescribing. Methods: A retrospective evaluation was conducted using electronic health data for adults ≥65 years old who presented to one of 15 primary care practices between 2019 and 2020 (n = 25,141). Chronic opioid and BZD users had ≥4 prescriptions in the year prior, with at least one in the last 90 or 180 days, respectively. We compared demographic characteristics between all older adults versus chronic opioid and BZD users. We used logistic regression to identify characteristics (age, sex, race, Medicaid use, fall history) associated with opioid and BZD co‐prescribing. Results: We identified 833 (3.3%) chronic opioid and 959 chronic BZD users (3.8%) among all older adults seen in these practices. Chronic opioid users were less likely to be Black (12.7% vs. 14.3%) or other non‐White race (1.4% vs. 4.3%), but more likely to be women (66.8% vs. 61.3%). A similar trend was observed for BZD users, with less prescribing among Black (5.4% vs. 14.3%) and other races (2.2% vs. 4.3%) older adults and greater prescribing among women (73.6% vs. 61.3%). Co‐prescribing was observed among 15% of opioid users and 13% of BZD users. Co‐prescribing was largely driven by the presence of relevant co‐morbid conditions including chronic pain, anxiety, and insomnia rather than demographic characteristics. Conclusions: We observed notable disparities in opioid and BZD prescribing by sex and race among older adults in primary care. Future research should explore if such patterns reflect appropriate prescribing or are due to disparities in prescribing driven by biases related to perceived risks for misuse. See related Editorial by Sloan and Hung in this issue. [ABSTRACT FROM AUTHOR]

Background: Antiepileptics are commonly prescribed to nursing home residents with Alzheimer's disease and related dementias (ADRD) but there is little scientific support for their use in this population. It is unclear whether different antiepileptics are targeting different indications. Methods: Using the Minimum Data Set and Medicare data, including Part D pharmacy claims, we constructed annual cohorts of residents with ADRD with long‐term stays in nursing homes from 2015 to 2019. For each year, we measured the proportion of residents with ADRD in nursing homes nationwide with at least one antiepileptic prescription. We also measured trends in valproic acid, gabapentin, antipsychotic, and opioid prescribing. Finally, we examined how prescribing rates differed based on whether residents with ADRD had disruptive behaviors or reported pain. Results: Our study sample includes 973,074 persons living with ADRD who had a long‐term stay in a nursing home, which was defined as at least 3 months. The proportion of residents with ADRD with at least one antiepileptic prescription increased from 29.5% in 2015 to 31.3% in 2019, which was driven by increases in the rate of valproic acid and gabapentin prescribing. Conversely, antipsychotic prescribing rates declined from 32.1% to 27.9% and opioid prescribing rates declined from 39.8% to 31.7%. The risk of valproic acid prescribing was 10.9 percentage points higher among residents with ADRD with disruptive behaviors, while the risk of being prescribed gabapentin was 13.9 percentage points higher among residents with ADRD reporting pain. Conclusions: Antiepileptic prescribing among nursing home residents with ADRD is increasing, while antipsychotic and opioid prescribing is declining. Examining antiepileptic prescribing to residents with ADRD who had disruptive behaviors and/or reported pain suggests that two of the most common antiepileptics, valproic acid and gabapentin, are being used in clinically distinct ways. Antiepileptic prescribing of questionable risk–benefit for dementia care warrants further scrutiny. See related editorial by Carnahan et al. in this issue. [ABSTRACT FROM AUTHOR]

The article presents a study which described the variation in the prevalence of antipsychotic and benzodiazepine prescribing among beneficiaries enrolled in hospice across states. Topics discussed include adjusted state-level prescribing rates for antipsychotics and benzodiazepines, variation in prescribing of antipsychotics and benzodiazepines between states among hospice enrollees in 2017, and limitations of the study.

Background: We sought to examine the effectiveness of the Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUiPPED) medication safety program in three emergency departments (EDs) within the largest health system in Rhode Island (RI) with funding through a quality incentive payment by a private insurance partner. Methods: This study utilized a quasi‐experimental interrupted time series design to implement EQUiPPED, a three‐prong intervention aimed at reducing potentially inappropriate medication (PIM) prescriptions to 5% or less per month. We included clinicians who prescribed medications to older ED patients during the pre‐and post‐intervention periods from July 2018 to January 2021. We determined the monthly rate of PIM prescribing among older adults discharged from the ED, according to the American Geriatrics Society Beers Criteria, using Poisson regression. Results: 247 ED clinicians (48% attendings [n = 119], 27% residents [n = 67], 25% advanced practice providers [n = 61]) were included in EQUiPPED, of which 92% prescribed a PIM during the study period. In the pre‐implementation period (July 2018–July 2019) the average monthly rate of PIM prescribing was 9.30% (95% CI: 8.82%, 9.78%). In the post‐implementation period (October 2019–January 2021) the PIM prescribing rate decreased significantly to 8.62% (95% CI: 8.14%, 9.10%, p < 0.01). During pre‐implementation, 1325 of the 14,193 prescribed medications were considered inappropriate, while only 1108 of the 13,213 prescribed medications in post‐implementation were considered inappropriate. The greatest reduction was observed among antihistamines, skeletal muscle relaxants, and benzodiazepines. Conclusions: EQUiPPED contributed to a modest improvement in PIM prescribing to older adults among clinicians in these RI EDs even in the midst of the COVID‐19 pandemic. The quality incentive funding model demonstrates a successful strategy for implementation and, with greater replication, could shape national policy regarding health care delivery and quality of care for older adults. [ABSTRACT FROM AUTHOR]

Background: The medication‐related death of a hospitalized older adult elucidated the inappropriateness of medication default doses in our electronic health record (EHR) for older adults. In response, we created and implemented the Geriatric Prescribing Context (GPC), an EHR‐based set of age‐specific dose and frequency defaults for patients 75 years and older, in July 2017. Inpatient medication orders aligned with GPC defaults and showed significant dose decreases at one year for nine of ten most commonly used medications. This follow‐up investigation examined GPC alignment of dose and frequency over the 42‐month time period after its implementation. Methods: Order data for the ten most commonly used medications at OHSU Hospital were collected retrospectively from July 2016 through December 2020. We used Statistical Process Control charts to assess the proportion of medication orders aligning with the GPC's recommendations. Signals of special cause were evaluated to identify time periods when shifts in process averages likely occurred and suspected shifts were assessed using binomial proportion tests. We used RStudio (RStudio, Inc., version 1.2.5001) and Microsoft Excel (2016) to perform statistical analyses and control charts, respectively. Results: The preimplementation phase of all medications displayed no special causes. After significant initial improvement in 2017, control charts revealed three different patterns of performance. Eight medications maintained the initial improvement with one medication displaying a second significant improvement at a later date. Two medications showed a subsequent decline in performance not statistically different from baseline. Overall, eight of the ten medications were prescribed at more age‐friendly doses and frequencies compared to baseline after 42 months. Conclusions: The GPC is an effective method to support safer prescribing for hospitalized older patients, but long‐term impacts may be medication‐specific. Further investigation is needed to ensure appropriate prescribing across drug classes and understand the GPC's impact on patient outcomes like adverse drug events. [ABSTRACT FROM AUTHOR]

The article describes the case of a 72-year-old patient with type 2 diabetes mellitus (T2DM) to examine the interplay between guideline-concordant prescribing and cost related nonadherence (CRN) within older adults. Topics discussed include Medicare prescription coverage, patient out of pocket cost, and CRN for higher cost brand name medications. Potential solutions and areas of additional research are explored.

In October 2021 the Food and Drug Administration released draft rules creating a new class of hearing aids to be sold over the counter. Since Medicare does not cover hearing aids, the ready availability of low‐cost aids is potentially good news for the millions of older Americans with hearing loss, a disorder that is associated with isolation, depression and poor health. However, better financial access to hearing aids will not necessarily translate into better hearing: many older people will need assistance in fitting, using and maintaining their aids. Policymakers, managers, and clinicians need to consider how to structure, fund and deliver these vital adjunctive services. See related editorial by Lin et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Older nursing home (NH) residents with glycemic overtreatment are at significant risk of hypoglycemia and other harms and may benefit from deintensification. However, little is known about deintensification practices in this setting. Methods: We conducted a cohort study from January 1, 2013 to December 31, 2019 among Veterans Affairs (VA) NH residents. Participants were VA NH residents age ≥65 with type 2 diabetes with a NH length of stay (LOS) ≥ 30 days and an HbA1c result during their NH stay. We defined overtreatment as HbA1c <6.5 with any insulin use, and potential overtreatment as HbA1c <7.5 with any insulin use or HbA1c <6.5 on any glucose‐lowering medication (GLM) other than metformin alone. Our primary outcome was continued glycemic overtreatment without deintensification 14 days after HbA1c. Results: Of the 7422 included residents, 17% of residents met criteria for overtreatment and an additional 23% met criteria for potential overtreatment. Among residents overtreated and potentially overtreated at baseline, 27% and 19%, respectively had medication regimens deintensified (73% and 81%, respectively, continued to be overtreated). Long‐acting insulin use and hyperglycemia ≥300 mg/dL before index HbA1c were associated with increased odds of continued overtreatment (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.14–1.65 and OR 1.35, 95% CI 1.10–1.66, respectively). Severe functional impairment (MDS‐ADL score ≥ 19) was associated with decreased odds of continued overtreatment (OR 0.72, 95% CI 0.56–0.95). Hypoglycemia was not associated with decreased odds of overtreatment. Conclusions: Overtreatment of diabetes in NH residents is common and a minority of residents have their medication regimens appropriately deintensified. Deprescribing initiatives targeting residents at high risk of harms and with low likelihood of benefit such as those with history of hypoglycemia, or high levels of cognitive or functional impairment are most likely to identify NH residents most likely to benefit from deintensification. This article comments on an article by Lam et al. and an editorial by Lega et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: In June 2019, the Advisory Committee on Immunization Practices recommended discontinuing the routine use of the pneumococcal conjugate vaccine (PCV13) among adults aged ≥65 years and instead recommended PCV13 be used based on shared clinical decision making (SCDM). Objectives: We wanted to assess among primary care physicians (1) knowledge and attitudes regarding the new SCDM PCV13 recommendation and (2) how the new recommendation will affect their likelihood of recommending PCV13 to adults aged ≥65 years. Design This was done by mail and internet‐based survey, which was conducted October 2019 through January 2020. The study was carried out on a nationally representative sample of general internists (GIMs) and family physicians (FPs). Results: The response rate was 64% (617/968, GIM 57%, FP 71%). Only 41% of respondents were aware of the SCDM PCV13 recommendation in adults aged ≥65 years; 76% agreed (37% "Strongly," 39% "Somewhat") that their patients aged ≥65 years will get confused by having a SCDM recommendation for PCV13 and a routine recommendation for the pneumococcal polysaccharide vaccine (PPSV23); 60% agreed (18% "Strongly," 42% "Somewhat") that they were unsure of what points to emphasize when having a SCDM conversation with an adult aged ≥65 years about receiving PCV13. Just over 50% reported they would be less likely to recommend PCV13 for adults aged ≥65 years as a result of the new recommendation, but 42% reported that their recommendation for PCV13 would not change. Conclusions: Word of the new ACIP recommendation for PCV13 for adults aged ≥65 years needs to be further disseminated. Investigation into why some physicians do not plan to change their recommendations is warranted. [ABSTRACT FROM AUTHOR]

Background/objectives: Limited knowledge exists regarding sex differences in prescribing potentially inappropriate medications (PIMs) for various multimorbidity patterns. This study sought to determine sex differences in PIM prescribing in older adults with cardiovascular‐metabolic patterns. Design: Retrospective cohort study. Setting: Health and Retirement Study (HRS) 2004–2014 interview data, linked to HRS‐Medicare claims data annualized for 2005–2014. Study sample: Six thousand three‐hundred and forty‐one HRS participants aged 65 and older with two and more chronic conditions. Measurements: PIM events were calculated using 2015 American Geriatrics Society Beers Criteria. Multimorbidity patterns included: "cardiovascular‐metabolic only," "cardiovascular‐metabolic plus other physical conditions," "cardiovascular‐metabolic plus mental conditions," and "no cardiovascular‐metabolic disease" patterns. Logistic regression models were used to determine the association between PIM and sex, including interaction between sex and multimorbidity categories in the model, for PIM overall and for each PIM drug class. Results: Women were prescribed PIMs more often than men (39.4% vs 32.8%). Overall, women had increased odds of PIM (Adj. odds ratio [OR] = 1.30, 95% confidence interval [CI]: 1.16–1.46). Women had higher odds of PIM than men with cardiovascular‐metabolic plus physical patterns (Adj. OR = 1.25, 95% CI: 1.07–1.45) and cardiovascular‐metabolic plus mental patterns (Adj. OR = 1.25, 95% CI: 1.06–1.48), and there were no sex differences in adults with a cardiovascular‐metabolic only patterns (Adj. OR = 1.13, 95% CI: 0.79–1.62). Women had greater odds of being prescribed the following PIMs: anticholinergics, antidepressants, antispasmodics, benzodiazepines, skeletal muscle relaxants, and had lower odds of being prescribed pain drugs and sulfonylureas compared with men. Conclusion: This study evaluated sex differences in PIM prescribing among adults with complex cardiovascular‐metabolic multimorbidity patterns. The effect of sex varied across multimorbidity patterns and by different PIM drug classes. This study identified important opportunities for future interventions to improve medication prescribing among older adults at risk for PIM. [ABSTRACT FROM AUTHOR]

Importance: The Centers for Medicare & Medicaid Services' (CMS) National Partnership to Improve Dementia Care in Nursing Homes ("CMS National Partnership") focuses on reducing antipsychotic prescribing to long‐term care residents. Hospice enrollment is not an exclusionary condition for the antipsychotic quality measure reported by CMS. It is unclear how prescribing in hospice may have been impacted by the initiative. Objective: Estimate the association of the CMS National Partnership with trends in antipsychotic prescribing among long‐term care residents in hospice. Design: Interrupted time‐series analysis of a 100% Minimum Data Set sample with linked hospice claims from 2011 to 2017. Setting: Long‐term care nursing facilities. Participants: Older adults ≥65 residing in long‐term care (n = 3,741,379) and limited to those enrolled in hospice (n = 821,610). Main outcome: Quarterly prevalence of antipsychotic and other psychotropic (antianxiety, hypnotic, antidepressant) use among long‐term care residents; overall and among residents with dementia, stratified by hospice enrollment. Results: From 2011 to 2017, parallel declines in antipsychotic prescribing were observed among long‐term care residents enrolled and not enrolled in hospice (hospice: decline from 26.8% to 18.7%; non‐hospice: decline from 23.0% to 14.4%). Following the 2012 CMS National Partnership, quarterly rates of antipsychotic prescribing declined significantly for both residents enrolled and not enrolled in hospice care. Declines in antipsychotic prescribing were greater for residents with dementia, with similar rates among residents enrolled and not enrolled in hospice. Among residents with dementia enrolled in hospice, use of other psychotropic medication classes including antianxiety, antidepressant, and hypnotic use remained relatively stable over time. Conclusions and relevance: Declines in antipsychotic prescribing during the CMS National Partnership occurred among long‐term care residents in hospice, where use may be deemed clinically appropriate. Nursing homes are an important location for the provision of dementia end‐of‐life care and the drivers of potentially unintended reductions in antipsychotic use merits further investigation. [ABSTRACT FROM AUTHOR]

Background/Objectives: Advanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery. Design: Retrospective observational study using the Multicenter Perioperative Outcomes Group data set. Setting: Thirty‐six institutions across the United States. Participants: A total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018. Intervention: None. Measurements: Total induction bolus dose of propofol administered. Results: The mean (SD) weight‐adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6–65.0), varying from 73.8% among patients aged 65–69 to 45.8% among patients aged 80 and older. Conclusion: The present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited. See related editorial by Devinney et al. in this issue. [ABSTRACT FROM AUTHOR]

This editorial comments on the article by Mailhot et al. [ABSTRACT FROM AUTHOR]

Background/Objectives: Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes. Design: Cross‐sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014–2016. Setting: Beneficiaries enrolled in the Medicare hospice benefit. Participants: Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022). Main outcome: Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing. Results: 70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non‐Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non‐Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72–0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64–0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics. Conclusions: Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice. [ABSTRACT FROM AUTHOR]

Objectives: Persons living with Alzheimer's disease (AD) may be at increased risk for prescribing cascades due to greater multimorbidity, polypharmacy, and the need for more complex care. Our objective was to assess the proportion of the antidopaminergic‐antiparkinsonian medication prescribing cascades among persons living with Alzheimer's disease. Setting: Two large administrative claims databases in the United States. Participants: We identified patients aged ≥50 on January 1, 2017, who were dispensed a drug used to treat Alzheimer's disease for at least 1 day in the 365 days prior to or on cohort entry date and who had medical and pharmacy coverage in the 365 days prior to the cohort entry date. We excluded individuals with a recent institutional stay. We identified incident antidopaminergic (antipsychotic/metoclopramide) use in the 183 days following cohort entry and identified subsequent incident antiparkinsonian drug use within 8 to 365 days. Results: There were 121,538 patients with Alzheimer's disease eligible for inclusion. Approximately 62% were women with a mean age of 79.5 (SD ± 8.6). The mean number of drugs dispensed was 9.2 (SD ± 4.9). There were 36 incident antiparkinsonian users among 4,534 incident antipsychotic/metoclopramide users (0.8%). Conclusion: We determined that the proportion of antidopaminergic‐antiparkinsonian medication prescribing cascades, widely considered as high‐priority, was low. Our approach can be used to assess the proportion of prescribing cascades in populations considered to be at high risk and to prioritize system‐level interventional efforts to improve medication safety in these patients. [ABSTRACT FROM AUTHOR]

Background/Objectives: Older adults (>75 years of age) represent two‐thirds of atherosclerotic cardiovascular disease (ASCVD) deaths. The 2013 and 2018 American multi‐society cholesterol guidelines recommend using at least moderate intensity statins for older adults with ASCVD. We examined annual trends and statin prescribing patterns in a multiethnic population of older adults with ASCVD. Design Retrospective longitudinal study using electronic health record (EHR) data from 2007 to 2018. Setting: A large multi‐specialty health system in Northern California. Participants: A total of 24,651 adults older than 75 years with ASCVD. Measurements Statin prescriptions for older adults with known ASCVD were trended over time. Multivariable regression models were used to identify predictors of statin prescription (logistic) after controlling for relevant demographic and clinical factors. Results: The study cohort included 24,651 patients older than 75 years; 48% were women. Although prescriptions for moderate/high intensity statins increased over time for adults over 75, fewer than half of the patients (45%) received moderate/high intensity statins in 2018. Women (odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.74, 0.80), patients who had heart failure (OR = 0.69; 95% CI = 0.65, 0.74), those with dementia (OR = 0.88; 95% CI = 0.82, 0.95) and patients who were underweight (OR = 0.64; 95% CI = 0.57, 0.73) were less likely to receive moderate/high intensity statins. Conclusions: Despite increasing prescription rates between 2007 and 2018, guideline‐recommended statins remained underused in older adults with ASCVD, with more pronounced disparities among women and those with certain comorbidities. Future studies are warranted to examine reasons for statin underuse in older adults with ASCVD. [ABSTRACT FROM AUTHOR]

Although prescribing is the most common intervention provided by physicians, limited research has examined the role of physician sex and gender on prescribing practices. In this article, we briefly summarize research relating to differences in prescribing behaviors based on physician sex and gender. To identify articles, PubMed was searched for studies from the last 20 years reporting on prescribing differences by physician sex or gender for the general population and specifically for older adults. We describe major themes emerging from the studies, illustrate findings from key studies, and note the major gaps in the literature, notably the lack of evidence on prescribing for older adults. Given the paucity of research in this area, we also explore evidence on the impact of physician sex and gender on other aspects of healthcare delivery, such as communication within the patient‐physician relationship, and consider how these findings may also apply to prescribing behaviors. In general, we note that female physicians have been observed to engage in more careful and conservative healthcare provision including prescribing. A careful and conservative approach to prescribing may reduce the incidence of adverse drug events in older adults and be linked to a more patient‐centered approach to care. To what extent these differences in prescribing are important for patient health outcomes is unknown, and further research is required to identify optimal prescribing practices that minimize harms. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Oral anticoagulation (OAC) is challenging in older patients with nonvalvular atrial fibrillation (NVAF) who are often frail and have cognitive impairment. We examined the characteristics of older NVAF patients associated with higher odds of physical and cognitive impairments. We also examined if these high‐risk patients have different OAC prescribing patterns and their satisfaction with treatment because it may impact optimal management of their NVAF. METHODS: The patients in the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE‐AF study cohort 2016–2018) had NVAF, were aged 65 and older, and eligible for the receipt of OAC. Measures included frailty (Fried Frailty scale), cognitive impairment (Montreal Cognitive Assessment Battery), OAC prescribing and type (direct oral anticoagulant [DOAC] or vitamin K antagonist [VKA]), depressive symptoms (Patient Health Questionnaire‐9), bleeding, stroke risk, and treatment benefit (Anti‐Clot Treatment Scale). RESULTS: Patients (n = 1,244) were 49% female, aged 76 (standard deviation = 7) years. A total of 14% were frail, and 42% had cognitive impairment. Frailty and cognitive impairment co‐occurred in 9%. Odds of having both impairments versus none were higher with depression (odds ratio [OR] = 4.62; 95% confidence interval [CI] = 2.59–8.26), older age (OR = 1.56; 95% CI = 1.29–1.88), lower education (OR = 3.81; 95%CI = 2.13–6.81), race/ethnicity other than non‐Hispanic White (OR = 7.94; 95% CI = 4.34–14.55), bleeding risk (OR = 1.43; 95% CI = 1.12–1.81), and stroke risk (OR = 1.35; 95% CI = 1.13–1.62). OAC prescribing was not associated with CI and frailty status. Among patients taking OACs (85%), those with both impairments were more likely to take DOAC than VKA (OR = 1.69; 95% CI = 1.01–2.80). Having both impairments (OR = 1.87; 95% CI = 1.08–3.27) or cognitive impairment (OR = 1.56; 95% CI = 1.09–2.24) was associated with higher odds of reporting lower treatment benefit. CONCLUSION: In a large cohort of older NVAF patients, half were frail or cognitively impaired, and 9% had both impairments. We highlight the characteristics of patients who may benefit from cognitive and physical function screenings to maximize treatment and enhance prognosis. Finally, the co‐occurrence of impairment was associated with low perceived benefit of treatment that may impede optimal management. [ABSTRACT FROM AUTHOR]