Search

Background the prevalence of adverse drug reactions (ADRs) in hospitalised older patients, their clinical presentations, causative drugs, severity, preventability and measurable outcomes are unclear, ADRs being an increasing challenge to older patient safety. Methods we systematically searched PubMed, Embase, EBSCO-CINAHL, the Cochrane Library, 'rey' literature and relevant systematic review bibliographies, published from database inception to March 2020. We included any study reporting occurrence of in-hospital ADRs as primary or secondary outcomes in hospitalised older adults (mean age ≥ 65 years). Two authors independently extracted relevant information and appraised studies for bias. Study characteristics, ADR clinical presentations, causative drugs, severity, preventability and clinical outcomes were analysed. Study estimates were pooled using random-effects meta-analytic models. Results from 2,399 abstracts, we undertook full-text screening in 286, identifying 27 studies (29 papers). Final analysis yielded a pooled ADR prevalence of 16% (95%CI 12–22%, I 2 98%, τ 2 0.8585), in a population of 20,153 hospitalised patients aged ≥65 years of whom 2,479 patients experienced ≥ one ADR. ADR ascertainment was highly heterogeneous. Almost 48.3% of all ADRs involved five presentations: fluid/electrolyte disturbances (17.3%), gastrointestinal motility/defaecation disorders (13.3%), renal disorders (8.2%), hypotension/blood pressure dysregulation disorders/shock (5.5%) and delirium (4.1%). Four drug classes accounted for 57.8% of causative medications i.e. diuretics (19.8%), anti-bacterials (14.8%), antithrombotic agents (12.2%) and analgesics (10.9%). Pooled analysis of severity was not feasible. Four studies reported the majority of ADRs as preventable (55–95%). Conclusions on average, 16% of hospitalised older patients experience significant ADRs, varying in severity and mostly preventable, with commonly prescribed drug classes accounting for most ADRs. [ABSTRACT FROM AUTHOR]

Objective: hip fracture is a common and serious condition associated with high mortality. This study aimed to identify pre-operative characteristics which are associated with an increased risk of mortality after hip fracture surgery.Design: systematic search of published and unpublished literature databases, including EMBASE, MEDLINE, AMED, CINAHL, PubMed and the Cochrane Library, was undertaken to identify all clinical studies on pre-operative predictors of mortality after surgery in hip fracture with at least 3-month follow-up. Data pertaining to the study objectives was extracted by two reviewers independently. Where study homogeneity was evidence, a meta-analysis of pooled relative risk and 95% confidence intervals was performed for mortality against pre-admission characteristics.Results: fifty-three studies including 544,733 participants were included. Thirteen characteristics were identified as possible pre-operative indicators for mortality. Following meta-analysis, the four key characteristics associated with the risk of mortality up to 12 months were abnormal ECG (RR: 2.00; 95% CI: 1.45, 2.76), cognitive impairment (RR: 1.91; 95% CI: 1.35, 2.70), age >85 years (RR: 0.42; 95% CI: 0.20, 0.90) and pre-fracture mobility (RR: 0.13; 95% CI: 0.05, 0.34). Other statistically significant pre-fracture predictors of increased mortality were male gender, being resident in a care institution, intra-capsular fracture type, high ASA grade and high Charlson comorbidity score on admission.Conclusions: this review has identified the characteristics of patients with a high risk of mortality after a hip fracture surgery beyond the peri-operative period who may benefit from comprehensive assessment and appropriate management.PROSPERO Registration Number: CRD42012002107. [ABSTRACT FROM AUTHOR]

Objective. To examine the association between work place exposure and CTS by meta-analysis, including analyses with respect to exposure to hand force, repetition, vibration and wrist posture.Methods. All relevant peer-reviewed articles published between January 1980 and December 2009 were identified by a systematic search using the MEDLINE, CINAHL and PubMed databases. Papers were critiqued independently by two researchers and the relevant exposure information was extracted. Using the raw data of exposed and unexposed cases, a cumulative effect of specific exposure risks were calculated for hand force, repetition, a combination of force and repetition, vibration and wrist posture using the statistical program, Stata version 11 (StataCorp, College Station, TX, USA). Heterogeneity, meta-regression, publication bias and subgroup sensitivity analyses were performed.Results. Thirty-seven studies from English-language literature met the inclusion criteria. Using National Institute for Occupational Health and Safety criteria for case definition, a significant positive association between CTS and hand force, repetition, use of vibratory tools and wrist posture was observed with approximate doubling of risk for all exposures. Significant heterogeneity among studies was observed for most exposures and metaregression analyses identified CTS case definition, study design, country and risk of bias score to be the significant determinants. When a more conservative definition of CTS was employed to include nerve conduction abnormality with symptoms and/or signs, risk factors significantly associated with an increased risk of CTS among exposed workers were: vibration [odds ratio (OR) 5.40; 95% CI 3.14, 9.31], hand force (OR 4.23; 95% CI 1.53, 11.68) and repetition (OR 2.26; 95% CI 1.73, 2.94). There was a non-significant trend for the association between CTS and combined exposure to both force and repetition (OR 1.85; 95% CI 0.99, 3.45) and wrist posture (OR 4.73; 95% CI 0.42, 53.32).Conclusion. Occupational exposure to excess vibration, increased hand force and repetition increase the risk of developing CTS. Workplace strategies to avoid overexposure to these risk factors should be implemented. [ABSTRACT FROM PUBLISHER]

Introduction The prevalence of frailty at population level is unclear. We examined this in population-based studies, investigating sources of heterogeneity. Methods PubMed, Embase, CINAHL and Cochrane Library databases were searched for observational population-level studies published between 1 January 1998 and 1 April 2020, including individuals aged ≥50 years, identified using any frailty measure. Prevalence estimates were extracted independently, assessed for bias and analysed using a random-effects model. Results In total, 240 studies reporting 265 prevalence proportions from 62 countries and territories, representing 1,755,497 participants, were included. Pooled prevalence in studies using physical frailty measures was 12% (95% CI = 11–13%; n  = 178), compared with 24% (95% CI = 22–26%; n  = 71) for the deficit accumulation model (those using a frailty index, FI). For pre-frailty, this was 46% (95% CI = 45–48%; n  = 147) and 49% (95% CI = 46–52%; n  = 29), respectively. For physical frailty, the prevalence was higher among females, 15% (95% CI = 14–17%; n  = 142), than males, 11% (95% CI = 10–12%; n  = 144). For studies using a FI, the prevalence was also higher in females, 29% (95% CI = 24–35%; n  = 34) versus 20% (95% CI = 16–24%; n  = 34), for males. These values were similar for pre-frailty. Prevalence increased according to the minimum age at study inclusion. Analysing only data from nationally representative studies gave a frailty prevalence of 7% (95% CI = 5–9%; n  = 46) for physical frailty and 24% (95% CI = 22–26%; n  = 44) for FIs. Conclusions Population-level frailty prevalence varied by classification and sex. Data were heterogenous and limited, particularly from nationally representative studies making the interpretation of differences by geographic region challenging. Common methodological approaches to gathering data are required to improve the accuracy of population-level prevalence estimates. Protocol registration PROSPERO-CRD42018105431. [ABSTRACT FROM AUTHOR]

Objective. This study examines the reported evidence of an association between benign joint hypermobility syndrome (BJHS) and psychological symptoms.Methods. A systematic review of published (AMED, CINAHL, MEDLINE, EMBASE, PubMed, Cochrane Library) and unpublished research databases (OpenGrey, the World Health Organization (WHO) International Clinical Trials Registry Platform, Current Controlled Trials, the UK National Research Register Archive) was performed from their inception to January 2013. Studies assessing the prevalence and incidence of psychological conditions for people diagnosed with BJHS were included. Meta-analysis assessing the odds ratio (OR) and standardized mean difference in severity of psychological conditions was performed. Methodological quality was assessed using the Critical Appraisal Skills Programme (CASP) appraisal tools.Results. Fourteen papers including 3957 participants, 1006 people with and 2951 controls without BJHS were eligible. The overall methodological quality was moderate. The results indicated that people with BJHS experience significantly greater perceptions of fear and more intense fear (P < 0.05) and have a higher probability of demonstrating agoraphobia (P < 0.05), anxiety (OR 4.39, 95% CI 1.92, 10.40), depression (OR 4.10, 95% CI 1.79, 9.41) and panic disorders (OR 6.72, 95% CI 2.22, 20.35) than those without BJHS (P &leq; 0.005). Neither anxiety nor depression have been assessed in childhood populations.Conclusion. People with BJHS commonly exhibit a range of symptoms related to anxiety and depression. Considerable emotional symptoms accompany BJHS. Further study is warranted to explore how these results relate to non-Mediterranean populations and children. However, the data suggest that targeting psychological symptoms could be an important approach to managing the range of symptoms reported in these patients. [ABSTRACT FROM PUBLISHER]

Background Delirium is a common complication clinically and is associated with the poor outcomes, yet it is frequently unrecognised and readily disregarded. Although the 3-minute diagnostic interview for confusion assessment method-defined delirium (3D-CAM) has been used in a variety of care settings, a comprehensive evaluation of its accuracy in all available care settings has not been performed. Objective This study aimed to evaluate the diagnostic test accuracy of the 3D-CAM in delirium detection through a systematic review and meta-analysis. Methods We systematically searched PubMed, EMBASE, the Cochrane Library, Web of Science, CINAHL (EBSCO) and ClinicalTrials.gov published from inception to 10 July 2022. The quality assessment of the diagnostic accuracy studies-2 tool was applied to evaluate methodological quality. A bivariate random effects model was used to pool sensitivity and specificity. Results Seven studies with 1,350 participants and 2,499 assessments were included, which were carried out in general medical wards, intensive care units, internal medical wards, surgical wards, recovery rooms and post-anaesthesia care units. The prevalence of delirium ranged from 9.1% to 25%. The pooled sensitivity and specificity were 0.92 (95% confidence interval [CI] 0.87–0.95) and 0.95 (95% CI 0.92–0.97), respectively. The pooled positive likelihood ratio was 18.6 (95% CI 12.2–28.2), the negative likelihood ratio was 0.09 (95% CI 0.06–0.14) and the diagnostic odds ratio was 211 (95% CI 128–349). Moreover, the area under the curve was 0.97 (95% CI 0.95–0.98). Conclusions The 3D-CAM has good diagnostic accuracy for delirium detection in different care settings. Further analyses illustrated that it had comparable diagnostic accuracy in older adults and patients with dementia or known baseline cognitive impairment. In conclusion, the 3D-CAM is recommended for clinical delirium detection. [ABSTRACT FROM AUTHOR]

Background regular physical exercise is essential to maintain or improve functional capacity in older adults. Multimorbidity, functional limitation, social barriers and currently, coronavirus disease of 2019, among others, have increased the need for home-based exercise (HBE) programmes and digital health interventions (DHI). Our objective was to evaluate the effectiveness of HBE programs delivered by DHI on physical function, health-related quality of life (HRQoL) improvement and falls reduction in older adults. Design systematic review and meta-analysis. Participants community-dwelling older adults over 65 years. Intervention exercises at home through DHI. Outcomes measures physical function, HRQoL and falls. Results twenty-six studies have met the inclusion criteria, including 5,133 participants (range age 69.5 ± 4.0–83.0 ± 6.7). The HBE programmes delivered with DHI improve muscular strength (five times sit-to-stand test, −0.56 s, 95% confidence interval, CI −1.00 to −0.11; P  = 0.01), functional capacity (Barthel index, 5.01 points, 95% CI 0.24–9.79; P  = 0.04) and HRQoL (SMD 0.18; 95% CI 0.05–0.30; P  = 0.004); and reduce events of falls (odds ratio, OR 0.77, 95% CI 0.64–0.93; P  = 0.008). In addition, in the subgroup analysis, older adults with diseases improve mobility (SMD −0.23; 95% CI −0.45 to −0.01; P  = 0.04), and balance (SMD 0.28; 95% CI 0.09–0.48; P  = 0.004). Conclusion the HBE programmes carried out by DHI improve physical function in terms of lower extremity strength and functional capacity. It also significantly reduces the number of falls and improves the HRQoL. In addition, in analysis of only older adults with diseases, it also improves the balance and mobility. [ABSTRACT FROM AUTHOR]

Objective. There is substantial uncertainty regarding the prevalence of depression in RA. We conducted a systematic review aiming to describe the prevalence of depression in RA.Methods. Web of Science, PsycINFO, CINAHL, Embase, Medline and PubMed were searched for cross-sectional studies reporting a prevalence estimate for depression in adult RA patients. Studies were reviewed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and a meta-analysis was performed.Results. A total of 72 studies, including 13 189 patients, were eligible for inclusion in the review. Forty-three methods of defining depression were reported. Meta-analyses revealed the prevalence of major depressive disorder to be 16.8% (95% CI 10%, 24%). According to the PHQ-9, the prevalence of depression was 38.8% (95% CI 34%, 43%), and prevalence levels according to the HADS with thresholds of 8 and 11 were 34.2% (95% CI 25%, 44%) and 14.8% (95% CI 12%, 18%), respectively. The main influence on depression prevalence was the mean age of the sample.Conclusion. Depression is highly prevalent in RA and associated with poorer RA outcomes. This suggests that optimal care of RA patients may include the detection and management of depression. [ABSTRACT FROM PUBLISHER]

Background the aim of this systematic review and meta-analysis was to update and synthesise the totality of research evidence on the effectiveness of acute geriatric unit (AGU) care for older adults admitted to hospital with acute medical complaints. Methods MEDLINE, CINAHL, CENTRAL and Embase databases were systematically searched from 2008 to February 2022. Screening, data extraction and quality grading were undertaken by two reviewers. Only trials with a randomised design comparing AGU care and conventional care units were included. Meta-analyses were performed in Review Manager 5.4 and the Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the certainty of evidence. The primary outcome was incidence of functional decline between baseline 2-week prehospital admission status and discharge and at follow-up. Results 11 trials recruiting 7,496 participants across three countries were included. AGU care resulted in a reduction in functional decline at 6-month follow-up (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.66–0.93; moderate certainty evidence) and an increased probability of living at home at 3-month follow-up (RR 1.06, 95% CI 0.99–1.13; high certainty evidence). AGU care resulted in little or no difference in functional decline at hospital discharge or at 3-month follow-up, length of hospital stay, costs, the probability of living at home at discharge, mortality, hospital readmission, cognitive function or patient satisfaction. Conclusions AGU care improves clinical and process outcomes for hospitalised older adults with acute medical complaints. Future research should focus on greater inclusion of clinical and patient reported outcome measures. [ABSTRACT FROM AUTHOR]

Objective Depressive disorders are common in long-term care (LTC), however, there is no one process used to detect depressive disorders in this setting. Our goal was to describe the diagnostic accuracy of depression detection tools used in LTC settings. Methods We conducted a systematic review and meta-analysis of diagnostic accuracy measures. The databases PubMed, EMBASE, PsycINFO and CINAHL were searched from inception to 10 September 2021. Studies involving persons living in LTC, assisted living residences or facilities, comparing diagnostic accuracy of depression tools with a reference standard, were included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess risk of bias. Results We identified 8,463 citations, of which 20 studies were included in qualitative synthesis and 19 in meta-analysis. We identified 23 depression detection tools (including different versions) that were validated against a reference standard. At a cut-off point of 6 on the Geriatric Depression Scale-15 (GDS-15), the pooled sensitivity was 73.6% (95% confidence interval (CI) 43.9%–76.5%), specificity was 76.5% (95% CI 62.9%–86.7%), and an area under the curve was 0.83. There was significant heterogeneity in these analyses. There was insufficient data to conduct meta-analysis of other screening tools. The Nursing Homes Short Depression Inventory (NH-SDI) had a sensitivity ranging from 40.0% to 98.0%. The 4-item Cornell Scale for Depression in Dementia (CSDD) had the highest sensitivity (67.0%–90.0%) for persons in LTC living with dementia. Conclusions There are 23 tools validated for detection of depressive disorders in LTC, with the GDS-15 being the most studied. Tools developed specifically for use in LTC settings include the NH-SDI and CSDD-4, which provide briefer options to screen for depression. However, more studies of both are needed to examine tool accuracy using meta-analyses. [ABSTRACT FROM AUTHOR]

Placental abruption and cardiovascular disease (CVD) have common etiological underpinnings, and there is accumulating evidence that abruption may be associated with future CVD. We estimated associations between abruption and coronary heart disease (CHD) and stroke. The meta-analysis was based on the random-effects risk ratio (RR) and 95% confidence interval (CI) as the effect measure. We conducted a bias analysis to account for abruption misclassification, selection bias, and unmeasured confounding. We included 11 cohort studies comprising 6,325,152 pregnancies, 69,759 abruptions, and 49,265 CHD and stroke cases (1967–2016). Risks of combined CVD morbidity-mortality among abruption and nonabruption groups were 16.7 and 9.3 per 1,000 births, respectively (RR = 1.76, 95% CI: 1.24, 2.50; I 2 = 94%; τ2 = 0.22). Women who suffered abruption were at 2.65-fold (95% CI: 1.55, 4.54; I 2 = 85%; τ2 = 0.36) higher risk of death related to CHD/stroke than nonfatal CHD/stroke complications (RR = 1.32, 95% CI: 0.91, 1.92; I 2 = 93%; τ2 = 0.15). Abruption was associated with higher mortality from CHD (RR = 2.64, 95% CI: 1.57, 4.44; I 2 = 76%; τ2 = 0.31) than stroke (RR = 1.70, 95% CI: 1.19, 2.42; I 2 = 40%; τ2 = 0.05). Corrections for the aforementioned biases increased these estimates. Women with pregnancies complicated by placental abruption may benefit from postpartum screening or therapeutic interventions to help mitigate CVD risks. [ABSTRACT FROM AUTHOR]

Objective The authors sought to systematically review the existing literature on the falls-related diagnostic test properties of the Functional Reach Test (FRT), single-leg stance test (SLST), and Tinetti Performance-Oriented Mobility Assessment (POMA) in older adults across settings and patient populations. Methods The PubMed, EMBASE, and CINAHL databases were searched (inception–July 2020). Inclusion criteria were participants aged 60 years or more, prospectively recorded falls, and the reporting of falls-related predictive validity. Manuscripts not published in English were excluded. Methodological quality of reporting was assessed using the Tooth Scale. Results Of 1071 studies reviewed, 21 met the inclusion criteria (12 POMA, 8 FRT, 6 SLST). Seven studies (58.3%) used a modified version of the POMA, and 3 (37.5%) used a modified FRT. For the outcome of any fall, the respective ranges of sensitivity and specificity were 0.076 to 0.615 and 0.695 to 0.97 for the POMA, 0.27 to 0.70 and 0.52 to 0.83 for the modified POMA, 0.73 and 0.88 for the FRT, 0.47 to 0.682 and 0.59 to 0.788 for the modified FRT, and 0.51 and 0.61 for the SLST in community-dwelling older adults. For the SLST, the sensitivity and specificity for recurrent falls in the community-dwelling setting were 0.33 and 0.712, respectively. Conclusion All the clinical tests of balance demonstrated an overall low diagnostic accuracy and a consistent inability to correctly identify fallers. None of these tests individually are able to predict future falls in older adults. Future research should develop a better understanding of the role that clinical tests of balance play in the comprehensive assessment of falls risk in older adults. Impact Neither the FRT, SLST, nor POMA alone shows consistent evidence of being able to correctly identify fallers across fall types, settings, or older adult subpopulations. These clinical tests of balance cannot substitute a comprehensive falls risk assessment and thus should be incorporated in practice solely to identify and track balance impairment in older adults. [ABSTRACT FROM AUTHOR]

Objective Exercise prevents falls in the general older population, but evidence is inconclusive for older adults living with cognitive impairment. We performed an updated systematic review and meta-analysis to assess the potential effectiveness of interventions for reducing falls in older persons with cognitive impairment. Methods PubMed, EMBASE, CINAHL, Scopus, CENTRAL and PEDro were searched from inception to 10 November 2020. We included randomised controlled trials (RCTs) that evaluated the effects of physical training compared to a control condition (usual care, waitlist, education, placebo control) on reducing falls among community-dwelling older adults with cognitive impairment (i.e. any stage of Alzheimer's disease and related dementias, mild cognitive impairment). Results We identified and meta-analysed nine studies, published between 2013 and 2020, that included 12 comparisons (N = 1,411; mean age = 78 years; 56% women). Overall, in comparison to control, interventions produced a statistically significant reduction of approximately 30% in the rate of falls (incidence rate ratio = 0.70; 95% CI, 0.52-0.95). There was significant between-trial heterogeneity (I2 = 74%), with most trials (n = 6 studies [eight comparisons]) showing no reductions on fall rates. Subgroup analyses showed no differences in the fall rates by trial-level characteristics. Exercise-based interventions had no impact on reducing the number of fallers (relative risk = 1.01; 95% CI, 0.90–1.14). Concerns about risk of bias in these RCTs were noted, and the quality of evidence was rated as low. Conclusions The positive statistical findings on reducing fall rate in this meta-analysis were driven by a few studies. Therefore, current evidence is insufficient to inform evidence-based recommendations or treatment decisions for clinical practice. PROSPERO Registration number: CRD42020202094. [ABSTRACT FROM AUTHOR]

Objective Lumbar radiculopathy (LR) is a pain syndrome caused by compression/irritation of the lumbar nerve root(s). Traction is a well-known and commonly used conservative treatment for LR, although its effectiveness is disputed. The purpose of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effects of different types of traction added to or compared with conservative treatments on pain and disability. Methods Data were obtained from CENTRAL, PUBMED, CINAHL, Scopus, ISI Web of Science, and PEDro from their inception to April 2020. All randomized controlled trials on adults with LR, using mechanical traction, and without any restriction regarding publication time or language were considered. Two reviewers selected the studies, evaluated the quality assessment, and extracted the results. Meta-analysis used a random-effects model. Eight studies met the inclusion criteria, and 5 were meta-analyzed. Results Meta-analyses of results from low-quality studies indicated that supine mechanical traction added to physical therapist treatments had significant effects on pain (g = −0.58 [95% confidence interval = −0.87 to −0.29]) and disability (g = −0.78 [95% confidence interval = −1.45 to −0.11]). Analyses of results from high-quality studies of prone mechanical traction added to physical therapist intervention for pain and disability were not significant. These results were also evident at short-term follow-up (up to 3 months after intervention). Conclusion The literature suggests that, for pain and disability in LR, there is short-term effectiveness of supine mechanical traction when added to physical therapist intervention. Impact This systematic review may be relevant for clinical practice due to its external validity because the treatments and the outcome measures are very similar to those commonly used in a clinical context. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to evaluate the effects of trigger point (TrP) dry needling alone or as an adjunct to other interventions on pain intensity and related disability in nontraumatic shoulder pain. Methods Ten databases were searched from inception to January 2020 for randomized clinical trials in which at least 1 group received TrP dry needling for shoulder pain of musculoskeletal origin with outcomes collected on pain intensity and related disability. Data extraction including participant and therapist details, interventions, blinding strategy, blinding assessment outcomes, and results were extracted by 2 reviewers. The risk of bias (Cochrane Risk of Bias, Cochrane Guidelines), methodological quality (Physiotherapy Evidence Database score), and evidence level (Grading of Recommendations Assessment, Development, and Evaluation approach) were assessed. The search identified 551 publications with 6 trials eligible for inclusion. Results There was moderate-quality evidence that TrP dry needling reduces shoulder pain intensity with a small effect (mean difference = −0.49 points, 95% CI = −0.84 to −0.13; standardized mean difference = −0.25, 95% CI = −0.42 to −0.09) and low-quality evidence that TrP dry needling improves related disability with a large effect (mean difference = −9.99 points, 95% CI −15.97 to −4.01; standardized mean difference = −1.14, 95% CI −1.81 to −0.47) compared with a comparison group. The effects on pain were only found at short term. The Cochrane Risk of Bias was generally low, but the heterogenicity of the results downgraded the evidence level. Conclusion Moderate- to low-quality evidence suggests positive effects of TrP dry needling for pain intensity (small effect) and pain-related disability (large effect) in nontraumatic shoulder pain of musculoskeletal origin, mostly at short term. Future clinical trials investigating long-term effects are needed. Impact Dry needling is commonly used for the management of musculoskeletal pain. This is the first meta-analysis to examine the effects of dry needling on nontraumatic shoulder pain. [ABSTRACT FROM AUTHOR]

Background Potentially inappropriate prescribing (PIP) may not have received as much attention in primary care settings (compared to tertiary hospital and nursing home settings), due to uncertainty about its prevalence in this healthcare setting. We conducted a systematic review with meta-analysis to summarise the prevalence of PIP specific to primary care settings and computed the population attributable risk (PAR) to estimate the impact of PIP in primary care. Method We searched PubMed, Embase, CINAHL, Web of Science, Scopus, PsycINFO and previous review articles for studies related to 'older persons', 'primary care' and 'inappropriate prescribing'. Two reviewers selected eligible articles, extracted data and evaluated risk of bias. Multilevel meta-analysis was conducted to pool the prevalence estimates across the included studies, while meta-regression was conducted to investigate the sources of heterogeneity. Results Of the 4,259 articles identified, we included 67 articles with 111 prevalence estimates and a total of 5,054,975 participants. Overall, PIP had a pooled prevalence of 33.3% (95% CI 29.7–37.0%). Based on population attributable risks, PIP explained 7.7–17.3% of adverse outcomes related to older persons in primary care. If current PIP prevalence is halved, 37–79 cases of adverse outcomes may potentially be prevented (per 1,000 adverse outcomes). Conclusions The findings demonstrate the relevance and potential impact of PIP specific to primary care settings. Given the increasingly central role that primary care plays in coordinating healthcare, the findings highlight the need to prioritise PIP intervention in primary care as a key strategy to reduce iatrogenic medication-related harm among older persons in current healthcare system. [ABSTRACT FROM AUTHOR]

Background: older adults are frequent users of emergency services and demonstrate high rates of adverse outcomes following emergency care. Objective: to perform a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool, to determine its predictive value in identifying adults ≥65 years at risk of functional decline, unplanned emergency department (ED) readmission, emergency hospitalisation or death within 180 days after index ED visit/hospitalisation. Methods: a systematic literature search was conducted in PubMed, EMBASE, CINAHL, EBSCO and the Cochrane Library to identify validation and impact analysis studies of the ISAR tool. A pre-specified ISAR score of ≥2 (maximum score 6 points) was used to identify patients at high risk of adverse outcomes. A bivariate random effects model generated pooled estimates of sensitivity and specificity. Statistical heterogeneity was explored and methodological quality was assessed using validated criteria. Results: thirty-two validation studies (n = 12,939) are included. At ≥2, the pooled sensitivity of the ISAR for predicting ED return, emergency hospitalisation and mortality at 6 months is 0.80 (95% confidence interval (CI) 0.70-0.87), 0.82 (95% CI 0.74-0.88) and 0.87 (95% CI 0.75-0.94), respectively, with a pooled specificity of 0.31 (95% CI 0.24-0.38), 0.32 (95% CI 0.24-0.41) and 0.35 (95% CI 0.26-0.44). Similar values are demonstrated at 30 and 90 days. Three heterogeneous impact analysis studies examined the clinical implementation of the ISAR and reported mixed findings across patient and process outcomes. Conclusion: the ISAR has modest predictive accuracy and may serve as a decision-making adjunct when determining which older adults can be safely discharged. [ABSTRACT FROM AUTHOR]

Background: Overweight and obesity are associated with breast cancer mortality. However, the relationship between postdiagnosis weight gain and mortality is unclear. We conducted a systematic review and meta-analysis of weight gain after breast cancer diagnosis and breast cancer-specific, all-cause mortality and recurrence outcomes.Methods: Electronic databases identified articles up through December 2014, including: PubMed (1966-present), EMBASE (1974-present), CINAHL (1982-present), and Web of Science. Language and publication status were unrestricted. Cohort studies and clinical trials measuring weight change after diagnosis and all-cause/breast cancer-specific mortality or recurrence were considered. Participants were women age 18 years or older with stage I-IIIC breast cancer. Fixed effects analysis summarized the association between weight gain (≥5.0% body weight) and all-cause mortality; all tests were two-sided.Results: Twelve studies (n = 23 832) were included. Weight gain (≥5.0%) compared with maintenance (<±5.0%) was associated with increased all-cause mortality (hazard ratio [HR] = 1.12, 95% confidence interval [CI] = 1.03 to 1.22, P = .01, I(2) = 55.0%). Higher risk of mortality was apparent for weight gain ≥10.0% (HR = 1.23, 95% CI = 1.09 to 1.39, P < .001); 5% to 10.0% weight gain was not associated with all-cause mortality (P = .40). The association was not statistically significant for those with a prediagnosis body mass index (BMI) of less than 25 kg/m(2) (HR = 1.14, 95% CI = 0.99 to 1.31, P = .07) or with a BMI of 25 kg/m(2) or higher (HR = 1.00, 95% CI = 0.86 to 1.16, P = .19). Weight gain of 10.0% or more was not associated with hazard of breast cancer-specific mortality (HR = 1.17, 95% CI = 1.00 to 1.38, P = .05).Conclusions: Weight gain after diagnosis of breast cancer is associated with higher all-cause mortality rates compared with maintaining body weight. Adverse effects are greater for weight gains of 10.0% or higher. [ABSTRACT FROM AUTHOR]

Background: urinary incontinence (UI) is a common symptom among older people, with a higher prevalence among frail older persons living in nursing homes. Despite consequences such as reduced health and quality of life, many older people do not seek help for their symptoms, resulting in missed opportunity for treatment. Objective: the aim of this study was to investigate the evidence and the effect of conservative treatment of UI and the quality of life among older and frail older persons. Methods: a systematic review of randomised controlled studies and prospective, non-randomised studies was conducted, evaluating interventions of conservative treatment of UI in an older population (65 years or older). A total of 23 studies fulfilled the inclusion criteria and 9 were of high or moderate quality. Fourteen studies were of low quality and were therefore excluded from the analysis. Results: documented and effective conservative treatments are available even for older persons with UI. Pelvic muscle exercise, physical training in combination with ADL, prompted voiding and attention training, and help to toilet are important treatments. In some studies, however, the evidence of effectiveness is limited. Conclusions: this systematic review concludes that there are conservative treatments for UI for older and frail older persons that reduce leakage and increase quality of life. There is however a need for further high-quality studies. [ABSTRACT FROM AUTHOR]

Background. Tyrosine kinase inhibitors (TKIs) targeting the epidermal growth factor receptor (EGFR) have been evaluated in patients with metastatic and advanced non-small cell lung cancer (NSCLC).The U.S. Food and Drug Administration initially granted accelerated approval to gefitinib but subsequently rescinded the authorization. Erlotinib and afatinib are similar compounds approved for the treatment of metastatic NSCLC. The objective of this study was to compare the efficacy and toxicity of erlotinib, gefitinib, and afatinib in NSCLC. Methods. We tabulated efficacy variables including overall response rate (ORR), progression-free survival (PFS), and overall survival (OS) and quantitated toxicities and rates of dose reductions and discontinuation. Summary odds ratios were calculated using random and fixed-effects models. An odds ratio was the summary measure used for pooling of studies. Results. We examined 28 studies including three randomized trials with afatinib. Clinical toxicities, including pruritus, rash, anorexia, diarrhea, nausea, fatigue, mucositis, paronychia, and anemia, were similar between erlotinib and gefitinib, although some statistical differences were observed. Afatinib treatment resulted in more diarrhea, rash, and paronychia compared with erlotinib and gefitinib. Regarding efficacy, similar outcomes were recorded for ORR, PFS, or OS in the total population and in specific subgroups of patients between erlotinib and gefitinib. All three TKIs demonstrated higher ORRs in first line in tumors harboring EGFR mutations. Conclusion. Gefitinib has similar activity and toxicity compared with erlotinib and offers a valuable alternative to patients with NSCLC. Afatinib has similar efficacy compared with erlotinib and gefitinib in first-line treatment of tumors harboring EGFR mutations but may be associated with more toxicity, although further studies are needed. Gefitinib deserves consideration for U.S. marketing as a primary treatment for EGFR-mutant NSCLC. [ABSTRACT FROM AUTHOR]

Objective To compare the overall levels of physical activity of older adults with chronic musculoskeletal pain and asymptomatic controls. Review Methods A systematic review of the literature was conducted using a Cochrane methodology and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta- Analyses statement. Major electronic databases were searched from inception until December 2012, including the Cochrane Library, CINAHL, EBSCO, EMBASE, Medline, PubMed, PsycINFO, and the international prospective register of systematic reviews. In addition, citation chasing was undertaken, and key authors were contacted. Eligibility criteria were established around participants used and outcome measures focusing on daily physical activity. A meta-analysis was conducted on appropriate studies. Results Eight studies met the eligibility criteria, four of these reported a statistically lower level of physical activity in the older adult sampl e with chronic pain compared with the asymptomatic group. It was possible to perform a non-heterogeneous meta-analysis on five studies. This established that 1,159 older adults with chronic pain had a significantly lower level of physical activity (−0.20, confidence interval 95% = −0.34 to −0.06, p = 0.004) compared with 576 without chronic pain. Conclusion Older adults with chronic pain appear to be less active than asymptomatic controls. Although this difference was small, it is likely to be clinically meaningful. It is imperative that clinicians encourage older people with chronic pain to remain active as physical activity is a central non-pharmacological strategy in the management of chronic pain and is integral for healthy aging. Future research should prioritize the use of objective measurement of physical activity. [ABSTRACT FROM AUTHOR]