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The article discusses the issue of polypharmacy and its negative health outcomes, particularly among older adults in Canada. It introduces the Canadian Medication Appropriateness and Deprescribing Network (CADeN) and describes the goals and outcomes of the CADeN 2023 National Meeting, which focused on strengthening relationships, sharing resources, and informing policy. The meeting emphasized equity, diversity, and inclusion, as well as the importance of indigenous perspectives in healthcare. Initiatives and research on medication appropriateness and deprescribing were discussed, along with strategies to reduce medication overload. The meeting highlighted the need for health policy reforms, equitable access to medications, patient engagement, and collaboration within the healthcare system. The CADeN network plans to continue its efforts to promote medication appropriateness in Canada. [Extracted from the article]

The article summarizes the Proceedings of the International Ambulatory Drug Safety Symposium held in Munich, Germany in June 2023. The symposium aimed to address challenges in maximizing ambulatory drug safety and brought together scientists from 12 countries. The symposium focused on knowledge generation and implementation, including innovations in research, risk prediction, surveillance, decision support, collaboration, and intervention design. The symposium discussed the challenges of improving medication safety in ambulatory care and emphasized the need for tailored interventions and alignment between knowledge generation and implementation efforts. Experts in pharmacoepidemiology, health services research, and clinical medicine participated in the symposium. [Extracted from the article]

Introduction and hypothesis: Many women consider urinary incontinence (UI) a normal part of ageing. This belief may contribute to delays in treatment seeking. This study examined the relationship among holding that belief, UI type and severity, impact on quality of life, management and healthcare seeking in a sample of older community-dwelling Canadian women. Methods: This was a secondary analysis of a controlled trial examining the impact of continence promotion workshops on UI self-management. All women who consented and provided baseline data were included in this analysis regardless of eligibility for the main study. Results: The sample included 4446 women (2022 with UI) of mean (SD) age 78.2 (9.0) years and BMI 26.6 (5.6). The belief that UI is normal for ageing was held by 2149 women [48.3% (83.7% of 1798 incontinent women)] and was not associated with age [adjusted odds ratio (OR) (95% CI): 1.00 (0.99, 1.01), p = 0.72] or perception of overall health. Women with this belief had more impaired QoL compared with the women who felt UI was not normal for ageing [mean (SD) 83.9 (19.4) vs. 87.4 (18.6) (p < 0.01)]. This belief remained unaffected by daily UI and pad use up to 2/day. Conclusions: More than two-thirds of women thought UI normal for ageing. This belief was not associated with age or perception of overall health. More severe incontinence and greater quantities of pad use did not make women less likely to hold this belief. [ABSTRACT FROM AUTHOR]

The goal of sex and gender analysis is to promote rigorous, reproducible and responsible science. Incorporating sex and gender analysis into experimental design has enabled advancements across many disciplines, such as improved treatment of heart disease and insights into the societal impact of algorithmic bias. Here we discuss the potential for sex and gender analysis to foster scientific discovery, improve experimental efficiency and enable social equality. We provide a roadmap for sex and gender analysis across scientific disciplines and call on researchers, funding agencies, peer-reviewed journals and universities to coordinate efforts to implement robust methods of sex and gender analysis. The authors discuss the potential for sex and gender analysis to foster scientific discovery, improve experimental efficiency and enable social equality. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The feasibility of use and long-term outcomes of vaginal pessaries for the management of pelvic organ prolapse (POP) in older women remains unknown. Our aim was to determine successful fit rates and outcomes among older women seeking care for POP. Methods: This was a retrospective cohort study of 304 consecutive women aged 65 years and older with symptomatic POP undergoing a pessary trial at the outpatient urogynecology clinic in Québec, Canada. Women successfully fitted with a pessary were followed, and survival curves were used to ascertain the median time to pessary discontinuation for women aged 65 to 74 years in comparison with women aged 75 years and older. Long-term use was defined as longer than 1 year. Predictors of a successful fitting and long-term discontinuation were ascertained using logistic and Cox regression analyses. Results: Half of the women attempting a pessary trial were aged 75 years and older, and 63 % were fitted successfully regardless of age. Women with a history of hysterectomy or reconstructive pelvic surgery, or those with posterior vaginal wall prolapse were more likely to fail initial insertion. For women aged 65 to 74 years and women aged 75 years and older, the cumulative probabilities of continued pessary use were 87.5 % and 80.8 % at 1 year, 80.6 % and 70.9 % at 2 years, and 62.1 % versus 37.8 % at 5 years. Erosions occurred in 19.3 % of long-term users, with women aged 75 years and older more likely to experience vaginal erosions (HR 3.2, 95 % CI 1.6 - 6.3) and discontinue pessary use. Conclusion: Pessary use is a feasible and acceptable treatment option for the long-term management of symptomatic prolapse in over 60 % of all women aged 65 years and older. [ABSTRACT FROM AUTHOR]

Aim: The use of multiple medications is rising steadily among older individuals, but little is known about the impact of polypharmacy at a population level, both over time and across countries. Surveillance of polypharmacy is required to overcome these gaps. There currently exists no standard population indicator of polypharmacy. The objective of this survey was to query expert opinion on establishing a gold standard method for polypharmacy surveillance at the population level. Methodology: We invited 71 experts in geriatrics, pharmacoepidemiology, pharmacology and surveillance to respond to an Internet-based survey. Participants were asked to rate their degree of agreement on statements related to the definition of polypharmacy, the goals of polypharmacy surveillance and knowledge transfer issues. Consensus was reached when 70 % of participants either strongly or moderately agreed with the statements. Qualitative content analysis was performed on optional comments provided by the participants. Results: Thirty individuals (42 %) completed the survey. Consensus was reached on most items. However, there was no agreement on a quantitative indicator of polypharmacy. Participants resolved that the indicator include a quality component, and that levels of polypharmacy be created. Defining exposure also proved problematic: cumulative (e.g. total annual number) and/or simultaneous (concomitant) prescriptions could be considered. Conclusions: A gold standard indicator of polypharmacy should include both quantity and quality. There is a need to better inform the relevant outcomes of polypharmacy, to identify the most appropriate threshold(s) and quality measure(s) of interest to decision makers. [ABSTRACT FROM AUTHOR]

Background: Both the 2012 Beers list and the American Geriatric Society 'Choosing Wisely' campaign suggest restraint in the use of sedative-hypnotics for the treatment of insomnia in older people. Sedative hypnotic agents continue to be widely prescribed even though their use in the elderly is associated with an increased risk of falls, fractures, and emergency hospitalizations. Objective: The aim of this study was to estimate the cost effectiveness of cognitive behavioral therapy (CBT) compared with sedative-hypnotics and no treatment for insomnia in the US Medicare population, adjusting for the risk of falls and related consequences. Methods: A model-based economic evaluation (decision tree) using the US Medicare perspective and a conservative annual temporal framework was conducted. Simulations were performed in a hypothetical cohort of Medicare beneficiaries suffering from insomnia. The main outcome measure was the incremental cost per quality-adjusted life year (QALY) gained. Sensitivity analyses assessed the robustness of the base-case analysis. Results: On an annual basis, CBT showed a dominance (cost: US$19,442; QALYs: 0.594) over sedative hypnotics (cost: US$32,452; QALYs: 0.552) and no treatment (cost: US$33,853; QALYs: 0.517). Assuming a willingness to pay of US$50,000, the net monetary benefit was positive for CBT (US$10,287) and negative for sedative hypnotics (−US$4,851) and no treatment (−US$7,993). CBT had a 95 % chance of being the dominant strategy, with results most sensitive to an older adult's baseline risk of falling. Conclusion: Failure to consider drug harms such as drug-induced falls and hospitalization represents a growing public health concern, significantly underestimating the cost of sedative-hypnotic therapy and loss in quality of life for the elderly. Public payers should reconsider reimbursement of sedative-hypnotic drugs as first-line treatment for insomnia in older adults. [ABSTRACT FROM AUTHOR]

Up to 50 % of heart failure patients suffer from lower urinary tract symptoms. Urinary incontinence has been associated with worse functional status in patients with heart failure, occurring three times more frequently in patients with New York Heart Association Class III and IV symptoms compared with those with milder disease. The association between heart failure and urinary symptoms may be directly attributable to worsening heart failure pathophysiology; however, medications used to treat heart failure may also indirectly provoke or exacerbate urinary symptoms. This type of drug-disease interaction, in which the treatment for heart failure precipitates incontinence, and removal of medications to relieve incontinence worsens heart failure, can be termed therapeutic competition. The mechanisms by which heart failure medication such as diuretics, angiotensin-converting enzyme (ACE) inhibitors and β-blockers aggravate lower urinary tract symptoms are discussed. Initiation of a prescribing cascade, whereby antimuscarinic agents or β3-agonists are added to treat symptoms of urinary urgency and incontinence, is best avoided. Recommendations and practical tips are provided that outline more judicious management of heart failure patients with lower urinary tract symptoms. Compelling strategies to improve urinary outcomes include titrating diuretics, switching ACE inhibitors, treating lower urinary tract infections, appropriate fluid management, daily weighing, and uptake of pelvic floor muscle exercises. [ABSTRACT FROM AUTHOR]

Background Comorbidity scores based on medical or prescription claims data are frequently used to control for confounding in pharmacoepidemiological studies. Performance of such scores in predicting the risk of death in community-dwelling elderly adults may be compromised by the absence of mental health and socioeconomic characteristics not captured in claims data. Objective The aim of the study was to assess the impact of adding mental health status and sociodemographic characteristics to the Geriatric Comorbidity Score (GCS), a score derived from prescription claims data in the Quebec community-dwelling elderly population. Methods We used the cohort study from the longitudinal Quebec Seniors' Health Survey (n = 1,494) conducted between 2005 and 2006. For each participant, we obtained mental health and socioeconomic characteristics through validated questionnaires, which we linked with the medical and prescription claims databases of the Quebec Health Insurance Agency [Régie de l'assurance maladie du Québec (RAMQ)]. The main study outcome was death within 1 year, ascertained using the Quebec death registry. The GCS was calculated from prescription claims data, with the c statistic as a measure of performance. Using backward stepwise selection, external variables (marital status, region, family income, social support, daily hassles, perceived physical and mental health status, presence of mental health disorders) were added to the logistic regression model and the marginal effect assessed by comparing the c statistic with and without each covariate. Results Over 1 year, 77 deaths (5.15 %) were reported. The c statistic for the GCS was calculated as 0.67 (95 % confidence interval 0.64, 0.70). Addition of sex and age to the score yielded a 2.4 % increase. The variable with the greatest impact on the c statistic was marital status (6.1 % increase). Though important contributors, social support and perceived mental health status did not significantly improve performance of the score. Conclusions While sex, age and marital status significantly improved performance of a predictive score in the community-dwelling elderly population, the absence of data on mental and physical health status did not appear to compromise the validity of claims-based scores. Combining comorbidity scores with other methods to control for confounding thus remains a useful tool in pharmacoepidemiological research. [ABSTRACT FROM AUTHOR]

Background: Mild cognitive deficits are experienced by 18% of community-dwelling older adults, many of whom do not progress to dementia. The effect of commonly used medication on subtle impairments in cognitive function may be under-recognized. Objective: The aim of the review was to examine the evidence attributing amnestic or non-amnestic cognitive impairment to the use of medication with anticholinergic, antihistamine, GABAergic or opioid effects. Methods: MEDLINE and EMBASE were searched for randomized, double-blind, placebo-controlled trials of adults without underlying central nervous system disorders who underwent detailed neuropsychological testing prior to and after oral administration of drugs affecting cholinergic, histaminergic, GABAergic or opioid receptor pathways. Seventy-eight studies were identified, reporting 162 trials testing medication from the four targeted drug classes. Two investigators independently appraised study quality and extracted relevant data on the occurrence of amnestic, non-amnestic or combined cognitive deficits induced by each drug class. Only trials using validated neuropsychological tests were included. Quality of the evidence for each drug class was assessed based on consistency of results across trials and the presence of a dose-response gradient. Results: In studies of short-, intermediate- and long-acting benzodiazepine drugs (n =68 trials), these drugs consistently induced both amnestic and non-amnestic cognitive impairments, with evidence of a dose-response relation- ship. H1 -antihistamine agents (n = 12) and tricyclic antidepressants (n = 15) induced non-amnestic deficits in attention and information processing. Non- benzodiazepine derivatives (n = 29) also produced combined deficits, but less consistently than benzodiazepine drugs. The evidence was inconclusive for the type of cognitive impairment induced by different bladder relaxant anti- muscarinics (n = 9) as well as for narcotic agents (n = 5) and antipsychotics (n= 5). Among healthy volunteers >60 years of age, low doses of commonly used medications such as lorazepam 0.5 mg, oxybutynin immediate release 5 mg and oxycodone 10 mg produced combined deficits. Conclusion: Non-amnestic mild cognitive deficits are consistently induced by first-generation antihistamines and tricyclic antidepressants, while benzodiazepines provoke combined amnestic and non-amnestic impairments. Risk-benefit considerations should be discussed with patients in order to enable an informed choice about drug discontinuation or substitution to potentially reverse cognitive adverse effects. [ABSTRACT FROM AUTHOR]

Background: Age-related differences in the way ratings of health related quality of life (HRQL) are produced are poorly understood, especially for older women.Objective: To examine age differences in critical dimensions of HRQL among older women using structural equation modelling. We hypothesized that physical, mental and social health domains would exert weaker total effects on HRQL among older middle-aged versus much older women.Methods: A model of HRQL was developed and confirmatory factor analysis (CFA) was used to test the structure of the model across two samples of community-dwelling women aged 55 years and older. The relationships between the constructs and the relative magnitude of direct and indirect effects on HRQL were evaluated in a series of path models, with women younger and older than age 70 tested separately.Results: The CFA model of HRQL showed excellent fit in both the national and verification samples (RMSEA 0.04 and 0.02 respectively). In the path model, the total effects of physical, mental and social health on general perceptions of HRQL were greater and more significant in middle-aged versus older women (beta coefficients 0.810, 0.277, 0.266, all P < 0.05 versus, 0.700, 0.189, and 0.057, P < 0.05 for physical and mental health only respectively).Conclusion: This HRQL model suggests different opportunities for intervention among older women to improve the outcomes along the path to HRQL. [ABSTRACT FROM AUTHOR]

Background: The objectives of this study were to examine age differences in the extent to which older Canadian women exercise and eat nutritiously, and to identify the interventions they desire to help them adopt and maintain physical and nutritional fitness., Methods: A cross-sectional postal survey of 5,000 community-dwelling women aged 55-95 was conducted across Canada in October 2003. The survey queried exercise frequency, nutritional risk, functional status, and factors deemed facilitative to adopting and maintaining a physically fit and nutritiously healthy lifestyle., Results: Data from 2,484 women were available for analysis; 31% were 75 years and older. Among women aged 55-74 versus those over age 75, 62% compared to 56% reported exercising 3 times/week for 20 minutes or longer (p = 0.003), 33% in both age groups were eating nutritiously, and 24% compared to 21% were both exercising and eating nutritiously. Thirty-five percent of women aged 55-74 who were not exercising or eating nutritiously desired increased availability of low-cost, suitable health promotion programs and additional written materials to improve these health habits, compared to 25% of women in the 75 year and older group (p < 0.001). Improved transportation to programs was the only intervention preferred by women aged 75 years and older (OR 1.66 (1.30-2.11)). Sedentary women and those at higher nutritional risk were two to three times more likely to identify encouragement from health professionals (OR 1.93 (1.48-2.52)), as well as from family and friends (OR 3.03 (1.89-4.85)) as important facilitators., Interpretation: Women aged 55-74 who do not exercise and eat nutritiously are most receptive to a variety of health-promoting community interventions.