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Background: While many studies have assessed and measured patient attitudes toward deprescribing, less quantitative research has addressed the provider perspective. We thus sought to describe provider knowledge, beliefs, and self‐efficacy to deprescribe, with a focus on opioids and sedative‐hypnotics. Methods: An electronic anonymous survey was distributed to primary care providers at Kaiser Permanente Washington. Two reminder emails were sent. The survey included 10 questions on general deprescribing, and six questions each specific to opioid and sedative‐hypnotic deprescribing. Knowledge questions used a multiple‐choice response option format. Questions addressing beliefs and self‐efficacy (i.e., confidence) used a 0–10 Likert scale. Scales were dichotomized at ≥7 to define agreement (belief questions) or confidence (self‐efficacy questions). We calculated descriptive statistics to summarize the responses. Results: Of 370 eligible primary care providers, 95 (26%) completed the survey. For general deprescribing questions, a majority believed that lack of patient willingness, withdrawal symptoms and fear of symptom return, and time constraints impeded deprescribing. Approximately half chose the correct answers about opioid deprescribing, 21% were confident that they could alleviate patient concerns about opioid tapering, and 32% were confident managing chronic non‐cancer pain without opioids. For sedative‐hypnotics, 64%–87% of respondents correctly answered questions about risks and the relative effectiveness of alternatives, but only one‐third correctly answered a question about sedative‐hypnotic tapering. Roughly half were confident in their ability to successfully engage patients in sedative deprescribing conversations and select alternatives. Only 54% and 34% were confident in writing a tapering protocol for opioids and sedative‐hypnotics, respectively. Conclusion: Results suggest that raising provider awareness of patient willingness to deprescribe, addressing knowledge gaps, and increasing self‐efficacy for deprescribing are important targets for improving deprescribing. Support for writing tapering protocols and prescribing evidence‐based drug and non‐drug alternatives may be important to improve care. [ABSTRACT FROM AUTHOR]

Background: Anticholinergic medications are associated with fall risk. Higher dopaminergic signaling may provide resilience to these effects. We tested interactions between anticholinergic medication use and dopaminergic genotype on risk for recurrent falls over 10 years.Methods: Participants in the Health, Aging, and Body Composition (Health ABC) study (n = 2 372, mean age = 73.6; 47.8% men; 60.0% White) without disability or anticholinergic use at baseline were followed for up to 10 years for falls. Medication use was documented in 7 of 10 years. Highly anticholinergic medications were defined by Beers criteria, 2019. Recurrent falls were defined as ≥2 in the 12 months following medication assessment. Generalized estimating equations tested the association of anticholinergic use with recurrent falls in the following 12 months, adjusted for demographics, health characteristics, and anticholinergic use indicators. Effect modification by dopaminergic genotype (catechol-O-methyltransferase [COMT]; Met/Met, higher dopamine signaling, n = 454 vs Val carriers, lower dopamine signaling, n = 1 918) was tested and analyses repeated stratified by genotype.Results: During follow-up, 841 people reported recurrent falls. Anticholinergic use doubled the odds of recurrent falls (adjusted odds ratio [OR] [95% CI] = 2.09 [1.45, 3.03]), with suggested effect modification by COMT (p = .1). The association was present in Val carriers (adjusted OR [95% CI] = 2.16 [1.44, 3.23]), but not in Met/Met genotype (adjusted OR [95% CI] = 1.70 [0.66, 4.41]). Effect sizes were stronger when excluding baseline recurrent fallers.Conclusion: Higher dopaminergic signaling may provide protection against increased 12-month fall risk from anticholinergic use. Assessing vulnerability to the adverse effects of anticholinergic medications could help in determination of risk/benefit ratio for prescribing and deprescribing anticholinergics in older adults. [ABSTRACT FROM AUTHOR]

Background: Certain classes of antihypertensive medication may have different associations with cognitive impairment.Objective: To examine the association between prevalent use of antihypertensive medications that stimulate (thiazides, dihydropyridine calcium channel blockers, angiotensin type I receptor blockers) versus inhibit (angiotensin-converting enzyme inhibitors, beta-blockers, non-dihydropyridine calcium channel blockers) type 2 and 4 angiotensin II receptors on cognitive impairment among older adults residing in Veterans Affairs (VA) nursing homes for long-term care.Methods: Retrospective cohort study. Long-term care residents aged 65 + years admitted to a VA nursing home from 2012 to 2019 using blood pressure medication and without cognitive impairment at admission. Main exposure was prevalent use of angiotensin II receptor type 2 and 4-'stimulating' (N = 589), 'inhibiting' (N = 3,219), or 'mixed' (N = 1,715) antihypertensive medication regimens at admission. Primary outcome was any cognitive impairment (Cognitive Function Scale).Results: Over an average of 5.4 months of follow-up, prevalent use of regimens containing exclusively 'stimulating' antihypertensives was associated with a lower risk of any incident cognitive impairment as compared to prevalent use of regimens containing exclusively 'inhibiting' antihypertensives (HR 0.83, 95% CI 0.74-0.93). Results for the comparison between 'mixed' versus 'inhibiting' regimens were in the same direction but not statistically significant (HR 0.96, 95% CI 0.88-1.06).Conclusion: For residents without cognitive impairment at baseline, prevalent users of regimens containing exclusively antihypertensives that stimulate type 2 and 4 angiotensin II receptors had lower rates of cognitive impairment as compared to prevalent users of regimens containing exclusively antihypertensives that inhibit these receptors. Residual confounding cannot be ruled out. [ABSTRACT FROM AUTHOR]

Background: Diabetes is a risk factor for Alzheimer's disease and related dementias (ADRD). Epidemiologic evidence shows an association between diabetes medications and ADRD risk; cell and mouse models show diabetes medication association with AD-related neuropathologic change (ADNC).Objective: This hypothesis-generating analysis aimed to describe autopsy-measured ADNC for individuals who used diabetes medications.Methods: Descriptive analysis of ADNC for Adult Changes in Thought (ACT) Study autopsy cohort who used diabetes medications, including sulfonylureas, insulin, and biguanides; total N = 118. ADNC included amyloid plaque distribution (Thal phasing), neurofibrillary tangle (NFT) distribution (Braak stage), and cortical neuritic plaque density (CERAD score). We also examined quantitative measures of ADNC using the means of standardized Histelide measures of cortical PHF-tau and Aβ1-42. Adjusted analyses control for age at death, sex, education, APOE genotype, and diabetes complication severity index.Results: Adjusted analyses showed no significant association between any drug class and traditional neuropathologic measures compared to nonusers of that class. In adjusted Histelide analyses, any insulin use was associated with lower mean levels of Aβ1-42 (-0.57 (CI: -1.12, -0.02)) compared to nonusers. Five years of sulfonylureas and of biguanides use was associated with lower levels of Aβ1-42 compared to nonusers (-0.15 (CI: -0.28, -0.02), -0.31 (CI: -0.54, -0.07), respectively).Conclusion: Some evidence exists that diabetes medications are associated with lower levels of Aβ1-42, but not traditional measures of neuropathology. Future studies are needed in larger samples to build understanding of the mechanisms between diabetes, its medications, and ADRD, and to potentially repurpose existing medications for prevention or delay of ADRD. [ABSTRACT FROM AUTHOR]

Background: Four prescription drugs (donepezil, galantamine, memantine, and rivastigmine) are approved by the US FDA to treat symptoms of Alzheimer's disease (AD). Even modest effectiveness could potentially reduce the population-level burden of AD and related dementias (ADRD), especially for women and racial/ethnic minorities who have higher incidence of ADRD.Objective: Describe the prevalence of antidementia drug use and timing of initiation relative to ADRD diagnosis among a nationally representative group of older Americans, and if there are disparities in prevalence and timing by sex and race/ethnicity.Methods: Descriptive analyses and logistic regressions of Medicare claims (2008-2016) for beneficiaries who had an ADRD or dementia-related symptom diagnosis, or use of an FDA approved drug for AD. We investigate prevalence of use and timing of treatment initiation relative to ADRD diagnosis across time and beneficiary characteristics (age, sex, race/ethnicity, socioeconomic status, comorbidities).Results: Among persons diagnosed with ADRD or related symptoms, 33.3% used an approved drug over the study period. Odds of use was higher among Whites than non-Whites. Among ADRD drug users, 40% initiated use within 6 months of the initial ADRD or related symptoms diagnosis, and 16% initiated prior to a diagnosis. We observed disparities by race/ethnicity: 28% of Asians, 24% of Hispanics, 16% of Blacks, and 15% of Whites initiated prior to diagnosis.Conclusions: The use of antidementia drugs is relatively low and varies widely by race/ethnicity. Heterogeneity in timing of initiation and use may affect health and cost outcomes, but these effects merit further study. [ABSTRACT FROM AUTHOR]

Background: Numerous interventions are available to boost medication adherence, but the targeting of these interventions often relies on crude measures of poor adherence. Group-based trajectory models identify individuals with similar longitudinal prescription filling patterns. Identifying distinct adherence trajectories may be more useful for targeting interventions, although the association between adherence trajectories and clinical outcomes is unknown.Objective: To examine the association between adherence trajectories for oral hypoglycemics and subsequent hospitalizations among diabetes patients.Design: Retrospective cohort study.Patients: A total of 16,256 Pennsylvania Medicaid enrollees, non-dually eligible for Medicare, initiating oral hypoglycemics between 2007 and 2009.Main Measures: We used group-based trajectory models to identify trajectories of oral hypoglycemics in the 12 months post-treatment initiation, using monthly proportion of days covered (PDC) as the adherence measure. Multivariable Cox proportional hazard models were used to examine the association between trajectories and time to first diabetes-related hospitalization/emergency department (ED) visits in the following year. We used the C-index to compare prediction performance between adherence trajectories and dichotomous cutpoints (annual PDC <80 vs. ≥80 %).Results: The mean annual PDC was 0.58 (SD 0.32). Seven trajectories were identified: perfect adherers (9 % of the cohort), nearly perfect adherers (31.4 %), moderate adherers (21.0 %), low adherers (11.0 %), late discontinuers (6.8 %), early discontinuers (9.7 %), and non-adherers with only one fill (11.1 %). Compared to perfect adherers, trajectories of moderate adherers (HR = 1.48, 95 % CI 1.25, 1.75), low adherers (HR = 1.51, 95 % CI 1.25, 1.83), and non-adherers with only one fill (HR = 1.35, 95 % CI 1.09, 1.67) had greater risk of diabetes-related hospitalizations/ED visits. Predictive accuracy was improved using trajectories compared to dichotomized cutpoints (C-index = 0.714 vs. 0.652).Conclusions: Oral hypoglycemic treatment trajectories were highly variable in this large Medicaid cohort. Low and moderate adherers and those filling only one prescription had a modestly higher risk of hospitalizations/ED visits compared to perfect adherers. Trajectory models may be valuable in identifying specific non-adherence patterns for targeting interventions. [ABSTRACT FROM AUTHOR]

Background: Poor medication adherence is a major public health problem in older adults often resulting in negative health outcomes. Objective: The objective of this review was to provide an updated summary of evidence from randomized controlled studies to determine whether interventions aimed at improving medication adherence also improve the health outcomes of older adults residing in community-based settings. Methods: Articles that assessed medication adherence interventions and related health outcomes in elderly individuals were identified through searches of MEDLINE (1970-June 2016), the Cochrane Database of Systematic Reviews (through to June 2016), and Google Scholar. Across the 12 included studies, interventions were grouped into three main categories: behavioral/educational ( n = 3), pharmacist-led ( n = 7), and reminder/simplification ( n = 2). Results: Among the behavioral/educational intervention studies, two showed improvements in both adherence and related health outcomes, whereas one found no changes in adherence or health outcomes. Among the pharmacist-led studies, three showed improvements in both adherence and related health outcomes, while three reported no changes in adherence or health outcomes. One found an improvement in adherence but not health outcomes. Among the reminder/simplification studies, both studies reported improvements in adherence without a significant impact on related health outcomes. Conclusion: This evidence-based review of medication adherence interventions in older adults revealed promising strategies in the larger context of a largely mixed body of literature. Future patient-centered and multidisciplinary interventions should be developed and tested using evidence-based principles to improve medication adherence and health outcomes in older adults. [ABSTRACT FROM AUTHOR]

Background: Medications to treat and prevent chronic disease have substantially reduced morbidity and mortality; however, their diffusion has been uneven. Little is known about prescribing of chronic disease medications by nurse practitioners (NPs) and physician assistants (PAs), despite their increasingly important role as primary care providers. Thus, we sought to conduct an exploratory analysis to examine prescribing of new chronic disease medications by NPs and PAs compared to primary care physicians (PCPs).Methods: We obtained prescribing data from IMS Health's Xponent™ on all NPs, PAs, and PCPs in Pennsylvania regularly prescribing anticoagulants, antihypertensives, oral hypoglycemics, and/or HMG-Co-A reductase inhibitors pre- and post-introduction of five new drugs in these classes that varied in novelty (i.e., dabigatran, aliskiren, sitagliptin or saxagliptin, and pitavastatin). We constructed three measures of prescriber adoption during the 15-month post-FDA approval period: 1) any prescription of the medication, 2) proportion of prescriptions in the class for the medication, and 3) time to adoption (first prescription) of the medication.Results: From 2007 to 2011, the proportion of antihypertensive prescriptions prescribed by NPs and PAs approximately doubled from 2.0 to 4.2 % and 2.2 to 4.9 %, respectively. Similar trends were found for anticoagulants, oral hypoglycemics, and HMG-Co-A reductase inhibitors. By 2011, more PCPs had prescribed each of the newly approved medications than NPs and PAs (e.g., 44.3 % vs. 18.5 % vs. 20 % for dabigatran among PCPs, NPs, and PAs). Across all medication classes, the newly approved drugs accounted for a larger share of prescriptions in the class for PCPs followed by PAs, followed by NPs (e.g., dabigatran: 4.9 % vs. 3.2 % vs. 2.8 %, respectively). Mean time-to-adoption for the newly approved medications was shorter for PCPs compared to NPs and PAs (e.g., dabigatran, 7.3 vs. 8.2 vs. 8.5 months; P all medications <0.001).Conclusions: PCPs were more likely to prescribe each of the newly approved medications per each measure of drug adoption, regardless of drug novelty. Differences in the rate and speed of drug adoption between PCPs, NPs, and PAs may have important implications for care and overall costs at the population level as NPs and PAs continue taking on a larger role in prescribing. [ABSTRACT FROM AUTHOR]

Background: Gait speed decline, an early marker of functional impairment, is a sensitive predictor of adverse health outcomes in older adults. The effect of potentially inappropriate medications, including drug-disease and drug-drug interactions, on gait speed decline is not well known. Objective: The aim of this study was to determine if drug interactions impair functional status as measured by gait speed. Methods: The sample included 2402 older adults with medication and gait speed data from the Health, Aging and Body Composition study. The independent variable was the frequency of drug-disease and/or drug-drug interactions at baseline and 3 additional years. The main outcome was a clinically meaningful gait speed decline of ≥0.1 m/s the year following drug interaction assessment. Adjusted odds ratios and 95 % confidence intervals (CIs) were calculated using multivariate generalized estimating equations for both the overall sample and a sample stratified by gait speed at time of drug interaction assessment. Results: The prevalence of drug-disease and drug-drug interactions ranged from 7.6 to 9.3 and 10.5 to 12.3 %, respectively, with few participants (3.8-5.7 %) having multiple drug interactions. At least 22 % of participants had a gait speed decline of ≥0.1 m/s annually. Drug interactions were not significantly associated with gait speed decline overall or in the stratified sample of fast walkers. There was some evidence, however, that drug interactions increased the risk of gait speed decline among those participants with slower gait speeds, though p values did not reach statistical significance (adjusted odds ratio 1.22; 95 % CIs 0.96-1.56; p = 0.11). Moreover, a marginally significant dose-response relationship was seen with multiple drug interactions and gait speed decline (adjusted odds ratio 1.40; 95 % CIs 0.95-2.04; p = 0.08). Conclusions: Drug interactions may increase the likelihood of gait speed decline among older adults with evidence of preexisting debility. Future studies should focus on frail elders with less physiological reserve who may be more susceptible to the harms associated with potentially inappropriate medications. [ABSTRACT FROM AUTHOR]

Background: Results from studies assessing the association between anticholinergic use and falls are mixed, and prior studies are limited in their ability to control for important potential confounders. Thus, we sought to examine the association between anticholinergic medication use, including over-the-counter medications, and recurrent falls in community-dwelling older women.Methods: We analyzed data from a prospective cohort study of women aged 65 to 79 years from the Women's Health Initiative Observational Study and Clinical Trials. Women were recruited between 1993 and 1998, and analyses included 61,451 women with complete information. Medications with moderate or strong anticholinergic effects were ascertained directly from drug containers during face-to-face interviews. The main outcome measure was recurrent falls (≥2 falls in previous year), which was determined from self-report within 1.5 years subsequent to the medication assessment.Results: At baseline, 11.3 % were using an anticholinergic medication, of which antihistamines (commonly available over-the-counter) were the most common medication class (received by 45.2 % of individuals on anticholinergic medication). Using multivariable GEE models and controlling for potential confounders, the adjusted odds ratio for anticholinergic medication use was 1.51 (95 % CI, 1.43-1.60) for recurrent falls. Participants using multiple anticholinergic medications had a 100 % increase in likelihood of recurrent falls (adjusted odds ratio 2.00, 95 % CI 1.73-2.32). Results were robust to sensitivity analysis.Conclusions: Anticholinergic medication use was associated with increased risk for recurrent falls. Our findings reinforce judicious use of anticholinergic medications in older women. Public health efforts should emphasize educating older women regarding the risk of using over-the-counter anticholinergics, such as first-generation antihistamines. [ABSTRACT FROM AUTHOR]

Objective. To present the fourth in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of twelve important contributors to pain and disability in older adults with CLBP. This article focuses on depression. Methods. The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a threemember content expert panel, and a nine-member primary care panel were involved in the iterative development of these materials. The algorithm was developed keeping in mind medications and other resources available within Veterans Health Administration (VHA) facilities. As panelists were not exclusive to the VHA, the materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributor's clinical practice. Results. We present an algorithm and supportive materials to help guide the care of older adults with depression, an important contributor to CLBP. The case illustrates an example of a complex clinical presentation in which depression was an important contributor to symptoms and disability in an older adult with CLBP. Conclusions. Depression is common and should be evaluated routinely in the older adult with CLBP so that appropriately targeted treatments can be planned and implemented. [ABSTRACT FROM AUTHOR]

Objectives To evaluate concordance of five commonly used anticholinergic scales. Design Cross-sectional secondary analysis. Setting Pittsburgh, Pennsylvania, and Memphis, Tennessee. Participants Community-dwelling adults aged 70 to 79 with baseline medication data from the Health, Aging, and Body Composition Study (N = 3,055). Measurements Any anticholinergic use, weighted scores, and total standardized daily dosage were calculated using five anticholinergic measures (Anticholinergic Cognitive Burden ( ACB) Scale, Anticholinergic Drug Scale ( ADS), Anticholinergic Risk Scale ( ARS), Drug Burden Index anticholinergic component ( DBI- ACh), and Summated Anticholinergic Medications Scale ( SAMS)). Concordance was evaluated using kappa statistics and Spearman rank correlations. Results Any anticholinergic use in rank order was 51% for the ACB, 43% for the ADS, 29% for the DBI- ACh, 23% for the ARS, and 16% for the SAMS. Kappa statistics for all pairwise use comparisons ranged from 0.33 to 0.68. Similarly, concordance as measured using weighted kappa statistics ranged from 0.54 to 0.70 for the three scales not incorporating dosage ( ADS, ARS, ACB). Spearman rank correlation between the DBI- ACh and SAMS was 0.50. Conclusion Only low to moderate concordance was found between the five anticholinergic scales. Future research is needed to examine how these differences in measurement affect their predictive validity with respect to clinically relevant outcomes, such as cognitive impairment. [ABSTRACT FROM AUTHOR]

Objectives To determine whether a clinical surveillance system could be used to detect drug-associated hypoglycemia events and determine their incidence in nursing home ( NH) residents. Design Retrospective cohort. Setting Four NHs in western Pennsylvania. Participants Any resident of the four NHs who had a computer-generated alert detecting potential drug-associated hypoglycemia over a 6-month period were included. Measurements Descriptive statistics were used to summarize all variables, including the frequency and distribution of alert type according to glucose threshold. Analyses were conducted according to numbers of alerts and residents. The medications associated with the drug-associated hypoglycemia alerts were identified, and frequency of their inclusion in alerts was calculated. Additional calculations included time to drug-associated hypoglycemic event alert from date of admission and frequency of events associated with postacute, short-stay (≤35 days) admissions. Results Seven hundred seventy-two alerts involving 141 residents were detected. Ninety (63.8%) residents had a glucose level of 55 mg/dL or less, and 42 (29.8%) had a glucose level of 40 mg/dL or less. Insulin orders were associated with 762 (98.7%) alerts. Overall incidence of drug-associated hypoglycemia events was 9.5 per 1,000 resident-days. Conclusion Hypoglycemia can be detected using a clinical surveillance system. This evaluation found a high incidence of drug-associated hypoglycemia in a general NH population. Future studies are needed to determine the potential benefits of use of a surveillance system in real-time detection and management of hypoglycemia in NHs. [ABSTRACT FROM AUTHOR]

Objectives To examine whether older adults taking nonsteroidal anti-inflammatory drugs ( NSAIDs) decreased the underuse of gastroprotective agents over time. Design Before-and-after study. Setting Health, Aging and Body Composition Study. Participants Daily users of a NSAID (prescription and over the counter ( OTC)) at visits in 2002-03 (preperiod; n = 404) and 2006-07 (postperiod; n = 172). The sample had a mean ± standard deviation age of 78.2 ± 2.7 at the preperiod visit and 81.9 ± 2.7 at the postperiod visit. The majority were white and female and had 12 or more years of education. Measurements Underusers were defined as persons taking nonselective NSAIDs who were at risk of peptic ulcer disease ( PUD; because of current warfarin or glucocorticoid use or history of PUD) and not using a proton pump inhibitor ( PPI) or persons taking cyclooxygenase 2 ( COX-2) selective NSAIDs and aspirin who were at risk of PUD (having at least one risk factor) and not using a PPI. Results Daily NSAID use decreased from 17.6% to 11.3% ( P < .001), and gastroprotective agent underuse decreased from 23.5% to 15.1% ( P = .008). Controlling for important covariates, having prescription insurance was somewhat protective against underuse in the preperiod (adjusted odds ratio ( AOR) = 0.78, 95% confidence interval ( CI) = 0.46-1.34; P = .37), but more so and significantly in the postperiod ( AOR = 0.41, 95% CI = 0.18-0.93; P = .03). Having prescription insurance was more protective in the post- than in the preperiod (less gastroprotective agent underuse; adjusted ratio of OR = 0.53, 95% CI = 0.22-1.29; P = .16), but this increased protection was not statistically significant. Conclusion In older daily NSAID users at high risk of PUD, having prescription insurance and adequate gastroprotective use was more common in the post- than in the preperiod. [ABSTRACT FROM AUTHOR]

Objective This study aims to evaluate correlates of gait speed, a measure of disability, in older adults with advanced knee osteoarthritis ( OA) and chronic pain. Design/Setting/Subjects/Methods Baseline data were analyzed from a clinical trial of 190 participants aged >50 with advanced knee OA (according to clinical and radiographic American College of Rheumatology criteria) and chronic pain. Data included 4-meter gait speed, quality of life (Short Form Health Survey 36 global health subscale), knee pain (Western Ontario and McMasters Universities Osteoarthritis Index [ WOMAC]), depressive symptoms (Center for Epidemiologic Studies Depression Scale), coping strategies (catastrophizing subscale and Cognitive Strategies Questionnaire), self-efficacy (Athritis Self-efficacy Scale [ ASES]), comorbidity (Cumulative Illness Rating Scale), analgesic use, and pain comorbidities (location, frequency, and intensity). A multivariable regression model was used to investigate these variables as they relate to gait speed. Results In the univariate analysis, the following variables were associated with gait speed: knee pain (per WOMAC), age, depressive symptoms, global health, catastrophizing, ASES function and other, comorbidity, and opioid use (all P values <0.05). In the fully adjusted multivariate model, controlling for knee pain, significant associations between gait speed and age ( β = −0.006; P < 0.001), ASES function ( β = 0.003; P < 0.001), and opioid use ( β = −0.082; P = 0.009) persisted. The correlation between opioid dose and gait speed (among opioid users) was not statistically significant ( r = 0.04; P = 0.81). Conclusion In a cross-sectional study of older adults with advanced knee OA and chronic pain, we found that age, arthritis function self-efficacy, and opioid use (but not dose) were significantly associated with decreased gait speed. [ABSTRACT FROM AUTHOR]

Objectives To assess the association between multiple pharmacy use and medication adherence and potential drug-drug interactions ( DDIs) in older adults. Design Cross-sectional propensity score-weighted analysis. Setting 2009 claims data. Participants A nationally representative sample of 926,956 Medicare Part D beneficiaries aged 65 and older continuously enrolled in fee-for-service Medicare and Part D that year who filled one or more prescriptions at a community retail or mail order pharmacy. Measurements Multiple pharmacy use was defined as concurrent (overlapping time periods) or sequential use (non-overlapping time periods) of ≥2 pharmacies in the year. Medication adherence was calculated using a proportion of days covered of 0.80 or greater for eight therapeutic categories (beta-blockers, renin angiotensin system antagonists, calcium channel blockers, statins, sulfonylureas, biguanides (metformin), thiazolidinediones, and dipeptidyl peptidase- IV inhibitors). Potential DDIs arising from use of certain drugs across a broad set of classes were defined as the concurrent filling of two interacting drugs. Results Overall, 38.1% of the sample used multiple pharmacies. Those using multiple pharmacies (concurrently or sequentially) consistently had higher adjusted odds of nonadherence (ranging from 1.10 to 1.31, P < .001) across all chronic medication classes assessed after controlling for sociodemographic, health status, and access to care factors than single pharmacy users. The adjusted predicted probability of exposure to a DDI was also slightly higher for those using multiple pharmacies concurrently (3.6%) than for single pharmacy users (3.2%, adjusted odds ratio ( AOR) = 1.11, 95% confidence interval ( CI) = 1.08-1.15) but lower in individuals using multiple pharmacies sequentially (2.8%, AOR = 0.85, 95% CI = 0.81-0.91). Conclusions Filling prescriptions at multiple pharmacies was associated with lower medication adherence across multiple chronic medications and a small but statistically significant greater likelihood of DDIs in concurrent pharmacy users. [ABSTRACT FROM AUTHOR]

Background: Clinical validation studies of the Healthcare Effectiveness Data and Information Set (HEDIS) measures of inappropriate prescribing in the elderly are limited. Objectives: The objective of this study was to examine associations of new exposure to high-risk medication in the elderly (HRME) and drug-disease interaction (Rx-DIS) with mortality, hospital admission, and emergency care. Methods: A retrospective database study was conducted examining new use of HRME and Rx-DIS in fiscal year 2006 (Oct 2005-Sep 2006; FY06), with index date being the date of first HRME/Rx-DIS exposure, or first day of FY07 if no HRME/Rx-DIS exposure. Outcomes were assessed 1 year after the index date. The participants were veterans who were ≥65 years old in FY06 and received Veterans Health Administration (VA) care in FY05-06. A history of falls/hip fracture, chronic renal failure, and/or dementia per diagnosis codes defined the Rx-DIS subsample. The variables included a number of new unique HRME drug exposures and new unique Rx-DIS drug exposure (0, 1, >1) in FY06, and outcomes (i.e., 1-year mortality, hospital admission, and emergency care) up to 1 year after exposure. Descriptive statistics summarized variables for the overall HRME cohort and the Rx-DIS subset. Multivariable statistical analyses using generalized estimating equations (GEE) models with a logit link accounted for nesting of patients within facilities. For these latter analyses, we controlled for demographic characteristics, chronic disease states, and indicators of disease burden the previous year (e.g., number of prescriptions, emergency/hospital care). Results: Among the 1,807,404 veterans who met inclusion criteria, 5.2 % had new HRME exposure. Of the 256,388 in the Rx-DIS cohort, 3.6 % had new Rx-DIS exposure. Multivariable analyses found that HRME was significantly associated with mortality [1: adjusted odds ratio (AOR) = 1.62, 95 % CI 1.56-1.68; >1: AOR = 1.80, 95 % CI 1.45-2.23], hospital admission (1: AOR = 2.31, 95 % CI 2.22-2.40; >1: AOR = 3.44, 95 % CI 3.06-3.87), and emergency care (1: AOR = 2.59, 95 % CI 2.49-2.70; >1: AOR = 4.18, 95 % CI 3.71-4.71). Rx-DIS exposure was significantly associated with mortality (1: AOR = 1.60, 95 % CI 1.51-1.71; >1: AOR = 2.00, 95 % CI 1.38-2.91), hospital admission for one exposure (1: AOR = 1.12, 95 % CI 1.03-1.27; >1: AOR = 1.18, 95 % CI 0.71-1.95), and emergency care for two or more exposures (1: AOR = 1.06, 95 % CI 0.97-1.15; >1: AOR = 2.0, 95 % CI 1.35-3.10). Conclusions: Analyses support the link between HRME/Rx-DIS exposure and clinically significant outcomes in older veterans. Now is the time to begin incorporating input from both patients who receive these medications and providers who prescribe to develop approaches to reduce exposure to these agents. [ABSTRACT FROM AUTHOR]

Objectives To describe facility-level variation in two measures of potentially inappropriate prescribing prevalent in Veterans Affairs ( VA) facilities-exposure to high-risk medications in elderly adults ( HRME) and drug-disease interactions ( Rx- DIS)-and to identify facility characteristics associated with high-quality prescribing. Design Cross-sectional. Setting VA Healthcare System. Participants Veterans aged 65 and older with at least one inpatient or outpatient visit in 2005-2006 ( N = 2,023,477; HRME exposure) and a subsample with a history of falls or hip fractures, dementia, or chronic renal failure (n = 305,059; Rx- DIS exposure). Measurements Incident use of any HRME ( iHRME) and incident Rx- DIS ( iRx- DIS) and facility-level rates and facility-level predictors of iHRME and iRx- DIS exposure, adjusting for differences in patient characteristics. Results Overall, 94,692 (4.7%) veterans had iHRME exposure. At the facility level, iHRME exposure ranged from 1.6% at the lowest facility to 12.8% at the highest (median 4.7%). In the subsample, 9,803 (3.2%) veterans had iRx-DIS exposure, with a facility-level range from 1.3% to 5.8% (median 3.2%). In adjusted analyses, veterans seen in facilities with formal geriatric education had lower odds of iHRME (odds ratio ( OR) = 0.86, 95% confidence interval ( CI) = 0.77-0.96) and iRx- DIS ( OR = 0.95, 95% CI = 0.88-1.01). Patients seen in facilities caring for fewer older veterans had greater odds of iHRME ( OR = 1.54, 95% CI = 1.35-1.75) and iRx- DIS exposure ( OR = 1.22, 95% CI = 1.11-1.33). Conclusion Substantial variation in the quality of prescribing for older adults exists across VA facilities, even after adjusting for patient characteristics. Higher-quality prescribing is found in facilities caring for a larger number of older veterans and facilities with formal geriatric education. [ABSTRACT FROM AUTHOR]

Objectives To describe the prevalence of unplanned hospitalizations caused by adverse drug reactions ( ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics. Design Retrospective cohort. Setting Veterans Affairs Medical Centers. Participants Six hundred seventy-eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006. Measurements Naranjo ADR algorithm, ADR preventability, and polypharmacy (0-4, 5-8, and ≥9 scheduled medications). Results Seventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta-blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin-converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health-status, and access-to-care variables, polypharmacy (≥9 and 5-8) was associated with greater risk of ADR-related hospitalization (adjusted odds ratio ( AOR) = 3.90, 95% confidence interval ( CI) = 1.43-10.61 and AOR = 2.85, 95% CI = 1.03-7.85, respectively). Conclusion ADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify prevalence and risk factors for exposure to drug-disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug-Disease Interaction (Rx-DIS) measure. DESIGN: Cross-sectional retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006. MEASUREMENTS: Rx-DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx-DIS exposure were examined, including demographic, health status, and access-to-care factors, including VA outpatient health services use and copayment status. RESULTS: Of the 305,041 older veterans who met criteria for inclusion, the 1-year prevalence of Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx-DIS. CONCLUSION: The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older adults. [ABSTRACT FROM AUTHOR]

Objective Although acute kidney injury (AKI) is well studied in the acute care setting, investigation of AKI in the nursing home (NH) setting is virtually nonexistent. The goal of this study was to determine the incidence of drug-associated AKI using the RIFLE (Risk, Injury, Failure, Loss of kidney function, or End-Stage kidney disease) criteria in NH residents. Design/Setting/Participants/Measurements We conducted a retrospective study between February 9, 2012, and February 8, 2013, for all residents at 4 UPMC NHs located in southwest Pennsylvania. The TheraDoc™ Clinical Surveillance Software System, which monitors laboratory and medication data and fires alerts when patients have a sufficient increase in serum creatinine, was used for automated case detection. An increase in serum creatinine in the presence of an active medication order identified to potentially cause AKI triggered an alert, and drug-associated AKI was staged according to the RIFLE criteria. Data were analyzed by frequency and distribution of alert type by risk, injury, and failure. Results Of the 249 residents who had a drug-associated AKI alert fire, 170 (68.3%) were women, and the mean age was 74.2 years. Using the total number of alerts (n = 668), the rate of drug-associated AKI was 0.41 events per 100 resident-days. Based on the RIFLE criteria, there were 191, 70, and 44 residents who were classified as AKI risk, injury, and failure, respectively. The most common medication classes included in the AKI alerts were diuretics, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs), and antibiotics. Conclusion Drug-associated AKI was a common cause of potential adverse drug events. The vast majority of cases were related to the use of diuretics, ACEIs/ARBs, and antibiotics. Future studies are needed to better understand patient, provider, and facility risk factors, as well as strategies to enhance the detection and management of drug-associated AKI in the NH. [ABSTRACT FROM AUTHOR]