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Background The objective of this study was to estimate the annual incidence rates of herpes zoster (HZ) and postherpetic neuralgia (PHN) among individuals aged ≥19 years and the proportion who received HZ vaccination among those aged ≥50 years. Methods This observational cohort study was conducted with administrative claims data from HealthVerity and included insured individuals across the US. Crude and US age- and sex-standardized incidence rates of HZ and PHN were calculated from 1 January 2019 to 31 May 2022 by calendar year in persons aged ≥19 years. Outcomes were defined as ≥1 ICD-10 diagnosis code for HZ or PHN. Analyses were stratified by age, sex, and immunocompromised status. Among those aged ≥50 years, the proportion who received 1 or 2 doses of recombinant zoster vaccine (Shingrix) or 1 dose of Zostavax was calculated. Results Standardized annual incidence rates from 2019 to 2021 were 542 to 685 per 100 000 person-years for HZ and 35 to 38 per 100 000 person-years for PHN. Rates were highest among females, older adults, and individuals who were immunocompromised. From 1 January 2019 to 31 May 2022, 4.3% and 9.0% of persons aged ≥50 years received 1 and 2 doses of Shingrix, respectively, and 0.2% received 1 dose of Zostavax. Conclusions In this US claims database analysis, HZ and PHN were more frequent among older adults, females, and individuals who were immunocompromised. Between 1 January 2019 and 31 May 2022, 9% of persons aged ≥50 years received 2 doses of the Shingrix vaccine. Greater efforts are needed to increase vaccine uptake against HZ, especially for those at highest risk. [ABSTRACT FROM AUTHOR]

The article discusses research which examined the prevalence and risk factors for falls and fall-related injuries in the 2018 National Post-acute and Long-term Care Study conducted by the U.S. National Center for Health Statistics. The study analyze the demographic or clinical characteristics of residential care community residents associated with falls and fall-related injuries. It attributes falls and injuries to functional and cognitive impairment, multimorbidity and antipsychotic drug use.

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]

Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2020. We selected high‐quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The first study, a noninferiority randomized clinical trial in England, evaluated whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events over the 12‐week follow‐up (domain: deprescribing). The second study, a prospective cohort study of women at Kaiser Permanente Southern, California, examined the association between bisphosphonate use and atypical femur fracture (domain: medication safety). The third study examined the effectiveness and safety of a multifaceted antimicrobial stewardship and quality improvement initiative in reducing unnecessary antimicrobial use for unlikely cystitis cases in noncatheterized residents in 25 nursing homes across the United States (domain: optimizing medication use). Lastly, the fourth study, a population‐based cohort study in the United Kingdom, examined the association of tramadol use with risk of hip fracture (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens. [ABSTRACT FROM AUTHOR]

Introduction: Although consistent use of tyrosine kinase inhibitors (TKIs) confers significant improvements in long-term survival for individuals with chronic myeloid leukemia (CML), only 70% of CML patients are adherent to TKIs. Understanding the factors that contribute to non-adherence and establishing dynamic adherence patterns in this population are essential aspects of targeted drug monitoring and intervention strategies. Methods: Newly diagnosed CML patients were identified in the MarketScan database and relevant covariate values extracted. Proportion of days covered (PDC) per 30-day interval was used to calculate adherence over a 12-month follow-up period. We conducted a latent profile analysis (LPA) on these PDC estimates to identify distinct, dynamic patterns of TKI adherence. Identified trajectories were grouped into four clinically relevant categories and predictors of membership in these categories were determined via multinomial logistic regression. Results: Four broad adherence categories were identified from the LPA: never adherent, initially non-adherent becoming adherent, initially adherent becoming non-adherent, and stable adherent. Results from the subsequent multinomial logistic regression indicated that younger age, female sex, greater monthly financial burden, fewer comorbidities, fewer concomitant medications, year of diagnosis, higher starting dose, TKI type, and a longer duration from diagnosis to treatment were significantly associated with membership in at least one of the three non-stable adherent groups. Conclusion: Select sociodemographic and clinical characteristics were found to predict membership in clinically meaningful groups of longitudinal TKI adherence. These findings could have major implications for informing personalized monitoring and intervention strategies for individuals who are likely to be non-adherent. [ABSTRACT FROM AUTHOR]

Background/objective: As pharmacists work to ensure reimbursement for chronic disease management services on the national level, evidence of their impact on important health metrics, such as medication adherence, is needed. However, summative evidence is lacking on the effectiveness of pharmacists to improve medication adherence in older adults. The objective was to assess the effectiveness of pharmacist‐led interventions on medication adherence in older adults (65+ years). Design/setting/participants: Using a systematic review and meta‐analytic approach, a comprehensive search of publications in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar was conducted through April 2, 2020 for randomized clinical trials of pharmacist‐led interventions to improve medication adherence in older adults. A standardized mean difference effect size (Cohen's d) was calculated for medication adherence in each study. Study effect sizes were pooled using a random‐effects model, with effect sizes weighted by inverse of its total variance. Measurements Medication adherence using any method of measurement. Results: Among 40 unique randomized trials of pharmacist‐led interventions with data from 8822 unique patients (mean age, range: 65–85 years), the mean effect size was 0.57 (k = 40; 95% Confidence Interval [CI]: 0.38–0.76). When two outlier studies were excluded from the analysis, the mean effect size reduced to 0.41 (k = 38; 95% CI: 0.27–0.54). A sensitivity analysis of medication adherence outcome by time point resulted in a mean effect size of 0.64 at 3 months (k = 12; 95% CI: 0.32–0.97), 0.30 at 6 months (k = 13; 95% CI: 0.11–0.48), 0.22 at 12 months (k = 12; 95% CI: 0.08–0.37), and 0.36 for outcome time points beyond 12 months (k = 5; 95% CI: 0.02–0.70). Conclusion: This meta‐analysis found a significant improvement in medication adherence among older adults receiving pharmacist‐led interventions. Implementation of pharmacist‐led interventions supported by Medicare reimbursement could ensure older adults' access to effective medication adherence support. [ABSTRACT FROM AUTHOR]

Background: Information on the prevalence of common imaging findings among patients without back pain in spine imaging reports might affect pain medication prescribing for patients with back pain. Prior research on inserting this text suggested a small reduction in opioid prescribing.Objective: To evaluate the effect of epidemiologic information in spine imaging reports on non-opioid pain medication prescribing for primary care patients with back pain.Design: Post hoc analysis of the Lumbar Imaging with Reporting of Epidemiology cluster-randomized trial.Participants: A total of 170,680 patients aged ≥ 18 years from four healthcare systems who received thoracolumbar, lumbar, or lumbosacral spine imaging from 2013 to 2016 and had not received a prescription for non-opioid pain medication in the preceding 120 days.Intervention: Text of age- and modality-specific epidemiologic benchmarks indicating the prevalence of common findings in people without back pain inserted into thoracolumbar, lumbar, or lumbosacral spine imaging reports at intervention clinics.Main Measures: Primary outcomes: any non-opioid prescription within 90 days after index imaging, overall, and by sub-class (skeletal muscle relaxants, NSAIDs, gabapentinoids, tricyclic antidepressants, benzodiazepines, duloxetine).Secondary Outcomes: count of non-opioid prescriptions within 90 days, overall, and by sub-class.Key Results: The intervention was not associated with the likelihood of patients receiving at least one prescription for new non-opioid pain-related medications, overall (adjusted OR, 1.02; 95% CI, 0.97-1.08) or by sub-class. The intervention was not associated with the number of prescriptions for any non-opioid medication (adjusted incidence rate ratio [IRR], 1.02; 95% CI, 0.99-1.04). However, the intervention was associated with more new prescriptions for NSAIDs (IRR, 1.12) and tricyclic antidepressants (IRR, 1.11).Conclusions: Inserting epidemiologic text in spine imaging reports had no effect on whether new non-opioid pain-related medications were prescribed but was associated with the number of new prescriptions for certain non-opioid sub-classes.Trial Registration: ClinicalTrials.gov identifier: NCT02015455. [ABSTRACT FROM AUTHOR]

Background: Medication management requires complex cognitive functioning, and therefore, difficulty taking medications might be an early sign of cognitive impairment and could be a risk factor for Alzheimer's disease and related dementias (ADRD). Accordingly, people with difficulty taking medications may benefit from more detailed cognitive screening, potentially aiding in the diagnosis of ADRD, which is underdiagnosed. We are unaware of evidence on medication management difficulties that precede a real-world ADRD diagnosis in the USA. Objective: Examine the association between difficulty taking medications and subsequent real-world ADRD diagnoses. Design: Case-control study, using Health and Retirement Study (HRS) survey data linked to Medicare claims. Participants: A total of 1461 HRS respondents with an ADRD diagnosis observed from 1993 to 2012 (cases), matched by year of birth, wave of HRS entry, and sex to 3771 controls with no ADRD diagnosis. Main Measures: We examined the association between diagnosis of ADRD and self-reported difficulty taking medications in the preceding years (1–2 and 3–4 years prior to case definition). Control individuals were assigned the index date from their matched case. Conditional logistic regressions adjusted for age, sex, race, education, and comorbidities. Key Results: Compared with matched controls, cases had higher prevalence of difficulty taking medications 1–2 years prior to diagnosis (11.0% versus 2.3%), and 3–4 years prior to diagnosis (5.8% versus 2.3%). Adjusted analyses showed that compared with individuals without ADRD, those with an ADRD diagnosis had more than four times higher odds of difficulty taking medications 1–2 years prior (OR = 4.56 (CI 3.30–6.31)), and more than two times higher odds of difficulty taking medications 3–4 years prior (OR = 2.41 (CI 1.61–3.59)). Conclusions: Odds of medication difficulty 1–2 years prior were more than four times greater for individuals with ADRD diagnoses compared with those without ADRD. Medication management difficulties may prompt further cognitive screening, potentially aiding in earlier recognition of ADRD. [ABSTRACT FROM AUTHOR]

Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected high‐quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non‐cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital re‐admission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens. [ABSTRACT FROM AUTHOR]

Adherence to imatinib in chronic myeloid leukemia (CML) patients is estimated to be as low as 70% despite its clinical benefit, and our understanding of the impact of nonadherence in this population is limited. This study presents a novel application of the Alternating Conditional Estimation (ACE) algorithm in newly diagnosed CML patients to map the full dose–response curve (DRC) and determine how the strength of this curve varies over time.We applied the ACE algorithm alongside a backward elimination procedure to detect the presence of time dependence and nonlinearity in the relationship between imatinib adherence and time-to-remission. An extended Cox model allowing for the flexible modeling of identified effects via unpenalized B-splines was subsequently fit and assessed.The substantial improvement in model fit associated with the extended Cox approach suggests that traditional Cox proportional hazards model assumptions do not hold in this setting. Results indicate that the DRC for imatinib is non-linearly increasing, with an attenuated effect above a 74% adherence rate. The strength of this effect on remission varied over time and was strongest in the initial months of treatment, reaching a peak around 90 days post-initiation (log hazard ratio: 2.12, 95% confidence interval: 1.47 to 2.66).Most patients that achieved remission did so by 4 months (120 days) with consistently high adherence, suggesting that this could be a critical time and duration for realizing treatment benefit and patient monitoring. Findings regarding the relationship between adherence and remission can additionally help guide the design of future studies. [ABSTRACT FROM AUTHOR]

Background: It is well established that individual medications that affect the central nervous system (CNS) increase falls risk in older adults. However, less is known about risks associated with taking multiple CNS-active medications.Methods: Employing a new user design, we used data from the Adult Changes in Thought study, a prospective cohort of community-dwelling people aged 65 and older without dementia. We created a time-varying composite measure of CNS-active medication exposure from electronic pharmacy fill data and categorized into mutually exclusive categories: current (within prior 30 days), recent (31-90 days), past (91-365 days), or nonuse (no exposure in prior year). We calculated standardized daily dose and identified new initiation. Cox proportional hazards models examined the associations between exposures and the outcome of fall-related injury identified from health plan electronic databases.Results: Two thousand five hundred ninety-five people had 624 fall-related injuries over 15,531 person-years of follow-up. Relative to nonuse, fall-related injury risk was significantly greater for current use of CNS-active medication (hazard ratio [HR] = 1.95; 95% CI = 1.57-2.42), but not for recent or past use. Among current users, increased risk was noted with all doses. Risk was increased for new initiation compared with no current use (HR = 2.81; 95% CI = 2.09-3.78). Post hoc analyses revealed that risk was especially elevated with new initiation of opioids.Conclusions: We found that current use, especially new initiation, of CNS-active medications was associated with fall-related injury in community-dwelling older adults. Increased risk was noted with all dose categories. Risk was particularly increased with new initiation of opioids. [ABSTRACT FROM AUTHOR]

Improving the quality of medication use and medication safety is an important priority for prescribers who care for older adults. The objective of this article was to identify key articles from 2018 that address these issues. In addition, we selected four of these articles to annotate, critique, and discuss their broader implications for clinical practice. The first study highlights a cluster‐randomized trial that utilized a pharmacist‐led education‐based intervention delivered to both patients and physicians to deprescribe four types of inappropriate medications (sedative‐hypnotics, first‐generation antihistamines, selective nonsteroidal anti‐inflammatory drugs, and glyburide). The second study, a nested case‐control study using data from within the UK Clinical Practice Research Datalink, examined the association between anticholinergic exposure, overall and by anticholinergic medication class, and dementia risk in 40 770 older adults. The third study, a longitudinal cohort study of 1028 Swedish older adults, examined the association between antihypertensive medications and incident dementia. The last study was a randomized, double‐blind, placebo‐controlled trial that investigated the effect of daily low‐dose aspirin (100 mg) for primary prevention on cardiovascular events and major hemorrhage in 19 144 community‐dwelling older adults. Collectively, this current article provides insight into the pertinent topics of medication use quality and safety in older adults and helps raise awareness about optimal prescribing in older adults. J Am Geriatr Soc 67:2458–2462, 2019 [ABSTRACT FROM AUTHOR]

Background: Robust evidence is lacking on optimal timing of statin administration and its impact on patient outcomes.Objective: This study aims to evaluate among incident statin users the relationship between those prescribed evening vs. daily dosing instructions, medication adherence, and changes in low-density lipoprotein cholesterol (LDL-c).Design: This is an observational cohort study at Sutter Health, a community-based healthcare system, 2010-2016.Participants: Patients were ≥ 35 years of age as of the first statin prescription (baseline), with 12 to 36 months of electronic health record activity before and after baseline. Incident use was defined as no statin prescription in 12 months prior to baseline.Main Measures: Differences in medication adherence (proportion of days covered ≥ 0.80) over 12 months from baseline and mean change in LDL-c between 12 and 24 months from baseline were measured using regression modeling, adjusting for baseline demographics and clinical, prescriber, and statin characteristics.Key Results: Among 31,252 patients with valid statin prescriptions between 2010 and 2016, 5099 eligible incident statin users (mean age, 63 years) were identified, of whom 53% were prescribed evening and 47% daily dosing instructions. No difference in likelihood of statin adherence over 12 months was observed for evening vs. daily dosing (adjusted odds ratio [OR] 0.90; 95% CI 0.75, 1.08). No differences were observed in mean change in LDL-c (adjusted mean difference 1.42 mg/dL; 95% CI - 1.02, 3.89) or likelihood of attaining LDL-c < 70 mg/dL (adjusted OR 0.83; 95% CI 0.67, 1.04) for evening vs. daily dosing over a mean of 19 months follow-up.Conclusions: Among incident statin users from a real-world clinical setting, those with daily and evening dosing instructions had similar adherence rates and mean changes in LDL-c. Given potential clinical equipoise for evening and daily dosing, clinicians should consider patient-tailored statin dosing instructions to reduce potentially unnecessary regimen complexity. [ABSTRACT FROM AUTHOR]

Objectives: To examine the association between central nervous system (CNS)‐active medication use and the risk of fall‐related injury in community‐dwelling older adults following dementia onset. Further, to evaluate increased risk at higher doses or with a greater number of CNS‐active medication classes. Methods: Participants included community‐dwelling older adults aged 65 years and older with a dementia diagnosis participating in the Adult Changes in Thought Study. From automated pharmacy data, a time‐varying composite measure of CNS‐active medication use was created. Central nervous system‐active medication use was classified as current (use within prior 30 days), recent (prior 31–90 days), past (prior 91–365 days), and nonuse (no exposure in prior year). For current users, standardized daily doses (SDDs) were calculated for each CNS‐active medication and summed across medications, and the number of CNS‐active medication classes used was also measured. The outcome was fall‐related injury based on emergency department, inpatient, and outpatient International Classification of Diseases, Ninth Revision (ICD‐9) and external cause of injury (E) codes. Results: Among 793 subjects, 303 fall‐related injuries occurred over a mean follow‐up of 3.7 years (2907 total person‐years). Relative to nonuse, fall risk was significantly higher for current use (adjusted hazard ratio [HR] 1.59, 95% confidence internal [CI] 1.19–2.12) but not for past or recent use. Among current users, increased risk was seen across SDD levels: HRs (95% CI): 1.77 (1.19–2.62), 1.79 (1.25–2.56), and 1.35 (0.96–1.92) for less than 1 SDD, 1 to less than 2 SDDs, and 2 or more SDDs, respectively (trend test, p=0.14). A trend was seen for increasing risk with a greater number of CNS‐active medication classes; however, this was not statistically significant (trend test, p=0.084). Conclusions: Current use of CNS‐active medications was associated with fall‐related injury in community‐dwelling older adults followed from time of dementia onset, with increased risk even with use of low doses. [ABSTRACT FROM AUTHOR]

Objective: In this study, we assessed patient knowledge, beliefs, and attitudes about brain health and strategies for Alzheimer's disease and related dementias (ADRD) prevention. Methods: We administered a Web-based survey consisting of 17 questions about brain health and strategies for ADRD prevention in a convenience sample of 1661 patients in an integrated healthcare delivery system in Washington state between February and March 2018. We calculated frequency distributions of the quantitative data and conducted inductive content analysis of qualitative data. Results: Most respondents were female (77%), 51-70 years of age (64%), and white (89%). Although most agreed it is possible to improve brain health and reduce personal ADRD risk, onethird lacked confidence that they could take action to reduce personal ADRD risk. Participants' responses to open-ended questions revealed 10 themes grouped into 3 organizing categories regarding their perceptions about how to prevent ADRD onset: (1) understand ADRD; (2) stay engaged; and (3) manage one's own health and healthcare. Conclusions: Survey respondents were engaged and aware of dementia prevention, but they lacked access to personally actionable evidence.. [ABSTRACT FROM AUTHOR]

We administered a mixed-method survey to 1,661 patients in a large health system to assess preferences toward antihypertensive use for dementia prevention. If a specific antihypertensive medication was shown to prevent or delay dementia, the vast majority (>90%) of respondents currently taking an antihypertensive reported that they would be willing to take that specific antihypertensive starting as early as mid-life. Concerns reported were potential side effects, lack of evidence of effectiveness, blood pressure being normal or low, and medication cost. Analysis of free-text responses revealed themes of concerns regarding evidence of effectiveness and health priorities. [ABSTRACT FROM AUTHOR]

Improving the quality of medication use and medication safety in older adults is an important public health priority and is of paramount importance for clinicians who care for them. We selected four important articles from 2017 that address these issues to annotate and critique, and we discuss the broader implications for optimizing medication use. A longer list of articles is given in an online appendix. The first study provides national data on the prevalence of central nervous system–active medication polypharmacy in older adults and how this has changed over a 9‐year period (2004–2013). The second study characterizes prevalence of and factors associated with nonadherence to antiepileptic drugs in 36,912 older adults with epilepsy, with an emphasis on minorities. The third study describes the extent of antibiotic use in residents of 381 long‐term care facilities (LTCF) in British Columbia, Canada, from 2007 to 2014. Finally, we discuss a meta‐analysis of 42 studies that evaluated the prevalence of hospital admissions caused by adverse drug reactions in older adults. This article is intended to provide a narrative review of important publications on medication use quality and safety for clinicians and researchers committed to optimizing medication use in older adults. J Am Geriatr Soc 66:2254–2258, 2018. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate associations between high‐density lipoprotein cholesterol (HDL) and non‐HDL‐C levels at specific ages and subsequent Alzheimer's disease (AD) risk. Design Prospective population‐based cohort study. Setting: Adult Changes in Thought (ACT) Study. Participants: Individuals aged 65 and older with no dementia at ACT Study entry. We identified separate, partially overlapping subcohorts of ACT participants who were eligible for each age band–specific analysis (50–59, n = 1,088; 60–69, n = 2,852; 70–79, n = 2,344; 80–89, n = 537). Measurements Exposure consisted of clinical measures of total cholesterol (TC) and HDL‐C from laboratory data during a given age band. Outcomes of incident AD were assessed post‐age band using standard research diagnostic criteria. Statistical analyses used adjusted Cox proportional hazards regression models for each exposure and outcome pair within an age band. Cholesterol exposures were modeled using cubic splines. Results: For non‐HDL‐C, we found a statistically significant association with AD risk in the 60 to 69 (omnibus p =.005) and 70 to 79 (omnibus p =.04) age bands, suggesting a potential U‐shaped relationship (greater risk at low and high levels). For example, in people aged 60 to 69, those with an average non‐HDL‐C level of 120 mg/DL had a 29% greater AD hazard (hazard ratio (HR)=1.29, 95% confidence interval (CI)=1.04–1.61) than those with an average non‐HDL‐C level of 160 mg/dL, whereas those with an average non‐HDL‐C level of 210 mg/dL had a 16% greater hazard (HR=1.16, 95% CI=1.01–1.33). We did not find a statistically significant association between HDL‐C and AD risk. Conclusion: People with low (120 mg/dL) and high (210 mg/dL) non‐HDL‐C levels during their 60s and 70s had modestly higher risk of AD than those with intermediate (160 mg/dL) levels. The extreme age bands (50s and 80s) had small sample sizes. J Am Geriatr Soc 66:2344–2352, 2018. [ABSTRACT FROM AUTHOR]

Background: For patients with type 2 diabetes and chronic kidney disease (CKD), high-quality evidence about the relative benefits and harms of oral glucose-lowering drugs is limited.Objective: To evaluate whether mortality risk differs after the initiation of monotherapy with either metformin or a sulfonylurea in Veterans with type 2 diabetes and CKD.Design: Observational, national cohort study in the Veterans Health Administration (VHA).Participants: Veterans who received care from the VHA for at least 1 year prior to initiating monotherapy treatment for type 2 diabetes with either metformin or a sulfonylurea between 2004 and 2009.Main Measures: Metformin and sulfonylurea use was assessed from VHA electronic pharmacy records. The CKD-EPI equation was used to estimate glomerular filtration rate (eGFR). The outcome of death from January 1, 2004, through December 31, 2009, was assessed from VHA Vital Status files.Key Results: Among 175,296 new users of metformin or a sulfonylurea monotherapy, 5121 deaths were observed. In primary analyses adjusted for all measured potential confounding factors, metformin monotherapy was associated with a lower mortality hazard ratio (HR) compared with sulfonylurea monotherapy across all ranges of eGFR evaluated (HR ranging from 0.59 to 0.80). A secondary analysis of mortality risk differences favored metformin across all eGFR ranges; the greatest risk difference was observed in the eGFR category 30-44 mL/min/1.73m2 (12.1 fewer deaths/1000 person-years, 95% CI 5.2-19.0).Conclusions: Initiation of metformin versus a sulfonylurea among individuals with type 2 diabetes and CKD was associated with a substantial reduction in mortality, in terms of both relative and absolute risk reduction. The largest absolute risk reduction was observed among individuals with moderately-severely reduced eGFR (30-44 mL/min/1.73m2). [ABSTRACT FROM AUTHOR]

Though it is well documented that antidepressants are associated with an increased risk of falls in older adults at the drug class level, the comparative risk between individual antidepressants for fall injury in older adults with depression is unknown. Currently, clinicians are making decisions at the drug class level without consideration of the potential that there could be safer choices within classes. We compared the risk of fall injury among initiators of bupropion, duloxetine, fluoxetine, paroxetine, and venlafaxine to those of (es)citalopram and, separately, sertraline. We performed a retrospective cohort study using the MarketScan® Medicare Supplemental claims from 2007 to 2019. Individuals had incident depression (washout in previous continually enrolled year) with a first antidepressant claim up to three months after depression diagnosis. Individuals were followed for the first three months of antidepressant use until the first occurrence of fall injury, change/discontinuation of antidepressant, discontinued insurance coverage, or end of study. Propensity score inverse probability of treatment-weighted Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals for each antidepressant comparison and fall injury. We identified 114,505 individuals (mean age 76.6 years, 68% female, 97% without prior fall). A higher risk of fall injury was associated with initiating bupropion (HR 1.20 to 1.61), duloxetine (HR 1.27 to 1.36), paroxetine (HR 1.14 to 1.22), and venlafaxine (HR 1.22 to 1.34) when compared to (es)citalopram or sertraline. New use of duloxetine, bupropion, paroxetine, and venlafaxine was associated with a higher risk of fall injury compared to (es)citalopram and sertraline. [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]

Non-adherence to medications is one of the largest contributors to sub-optimal health outcomes. Many theories of adherence include a ‘value–expectancy’ component in which a patient decides to take a medication partly based on expectations about whether it is effective, necessary, and tolerable. We propose reconceptualising this common theme as a kind of ‘causal learning’ – the patient learns whether a medication is effective, necessary, and tolerable, from experience with the medication. We apply cognitive psychology theories of how people learn cause–effect relations to elaborate this causal-learning challenge. First, expectations and impressions about a medication and beliefs about how a medication works, such as delay of onset, can shape a patient’s perceived experience with the medication. Second, beliefs about medications propagate both ‘top-down’ and ‘bottom-up’, from experiences with specific medications to general beliefs about medications and vice versa. Third, non-adherence can interfere with learning about a medication, because beliefs, adherence, and experience with a medication are connected in a cyclic learning problem. We propose that by conceptualising non-adherence as a causal-learning process, clinicians can more effectively address a patient’s misconceptions and biases, helping the patient develop more accurate impressions of the medication. [ABSTRACT FROM PUBLISHER]

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: Despite wide-spread use of antihypertensives in older adults, the literature is unclear about their association with incident recurrent falls over time.Methods: Health, Aging and Body Composition study participants (n = 2,948) who were well functioning at baseline (1997) were followed to Year 7 (2004). The main outcome was recurrent falls (≥2) in the ensuing 12 months. Antihypertensive use was examined as: (a) any versus none, (b) long- versus short-term (≥2 vs <2 years), and by (c) summated standardized daily dose (SDD; 1 = maximum recommended daily dose for one antihypertensive), and (d) subclass.Results: Controlling for potential demographic, health status/behavior and access to care confounders, we found no increase in risk of recurrent falls in antihypertensive users compared to nonusers (adjusted odds ratio [AOR] = 1.13; 95% CI = 0.88-1.46), or those taking higher SDDs or for longer durations. Only those using a loop diuretic were found to have a modest increased risk of recurrent falls (AOR = 1.50; 95% CI = 1.11-2.03).Conclusions: Antihypertensive use overall was not statistically significantly associated with recurrent falls after adjusting for important confounders. Loop diuretic use may be associated with recurrent falls and needs further study. [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]

Background: Anticholinergic medication use has been associated with several negative health outcomes in older adults, but little is known about its risk for fractures. Objective: To examine the association between anticholinergic medication use and fracture outcomes in community-dwelling postmenopausal women. Methods: Utilizing a prospective cohort design, we examined data collected from 137,408 women aged 50-79 years from the Women's Health Initiative observational study and clinical trials not reporting hip fracture at baseline. Medications with moderate or strong anticholinergic effects were identified directly from drug containers during in-person interviews. The main outcome was fractures (hip, lower arm/wrist and total fractures). We performed multivariable Cox proportional hazard survival modelling to assess the association between anticholinergic use and the risk of fractures. Results: At baseline, 10.6 % of the women were using an anticholinergic medication, of which antihistamines were the most common medication class (48.4 %). The multivariable-adjusted hazard ratios for anticholinergic medication use were 1.08 (95 % confidence interval [CI] 0.89-1.30) for hip fracture, 1.01 (95 % CI 0.91-1.13) for lower arm/wrist fracture and 1.03 (95 % CI 0.98-1.09) for total fractures. We observed no association according to subclass or count of anticholinergic medications, or trends between the duration of anticholinergic use and any of the fracture outcomes. Conclusion: Anticholinergic medication use was not associated with an increased risk of fractures among community-dwelling women. Future research should make efforts to capture over-the-counter medication use and the cumulative anticholinergic burden in relation to important health outcomes for older adults. [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]

Background. Studies of drug-related hospitalizations have focused on adverse drug reactions, but few data are available on therapeutic failures (TFs) and adverse drug withdrawal events (ADWEs) leading to hospitalization among community-dwelling older adults. Thus, we sought to describe the prevalence of unplanned hospitalizations caused by TFs and ADWEs. In addition, we evaluated factors associated with these events in a nationally representative sample of older Veterans. Methods. This study included 678 randomly selected unplanned hospitalizations of older (age ≥ 65 years) Veterans between December 1, 2003, and November 9, 2006. The main outcomes were hospitalizations caused by a TF and/or an ADWE as determined by a pair of health professionals from review of medication charts and application of the Therapeutic Failure Questionnaire and/or Naranjo ADWE algorithm, respectively. Preventability (ie, medication error) of the admission was also assessed. Results. Thirty-four TFs and eight ADWEs involving 54 drugs were associated with 40 (5.9%) Veterans’ hospitalizations; of these admissions, 90.0% (36/40) were rated as potentially preventable mostly due to medication nonadherence and suboptimal prescribing. The most common TFs that occurred were heart failure exacerbations (n = 8), coronary heart disease symptoms (n = 6), tachyarrhythmias (n = 3), and chronic obstructive pulmonary disease exacerbations (n = 3). Half (4/8) of the ADWEs that occurred were cardiovascular in nature. Multivariable logistic regression modeling indicated that black Veterans (adjusted odds ratio 2.92, 95% CI 1.25–6.80) were significantly more likely to experience a TF-related admission compared with white Veterans. Conclusions. TF-related unplanned hospitalizations occur more frequently than ADWE-related admissions among older Veterans. Almost all TFs and/or ADWEs are potentially preventable. [ABSTRACT FROM PUBLISHER]

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]

Objective. To examine the prevalence and correlates of non-opioid and opioid analgesic use and descriptively evaluate potential undertreatment in a sample of community-dwelling elders with symptomatic knee and/or hip osteoarthritis (OA). Design. Cross-sectional. Setting. Health, Aging, and Body Composition Study. Patients. Six hundred and fifty-two participants attending the year 6 visit (2002-03) with symptomatic knee and/or hip OA. Outcome Measures. Analgesic use was defined as taking ≥1 non-opioid and/or ≥1 opioid receptor agonist. Non-opioid and opioid doses were standardized across all agents by dividing the daily dose used by the minimum effective analgesic daily dose. Inadequate pain control was defined as severe/extreme OA pain in the past 30 days from a modified Western Ontario and McMaster Universities Osteoarthritis Index. Results. Just over half (51.4%) reported taking at least one non-opioid analgesic and approximately 10% was taking an opioid, most (88.5%) of whom also took a non-opioid. One in five participants (19.3%) had inadequate pain control, 39% of whom were using <1 standardized daily dose of either a non-opioid or opioid analgesic. In adjusted analyses, severe/extreme OA pain was significantly associated with both non-opioid (adjusted odds ratio [AOR] = 2.44; 95% confidence interval [95% CI] = 1.49-3.99) and opioid (AOR = 2.64; 95% CI = 1.26-5.53) use. Conclusions. Although older adults with severe/extreme knee and/or hip OA pain are more likely to take analgesics than those with less severe pain, a sizable proportion takes less than therapeutic doses and thus may be undertreated. Further research is needed to examine barriers to optimal analgesic use. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented discussing medication reconciliation in the hospital admissions process.

A letter to the editor is presented which discusses the role of older peoples' medication management skills in their transitions from skilled nursing facilities (NSFs) to home,.

The article looks at a study on the effect of daily pill bottle alarms combined with individual or partner feedback reports on statin medication adherence. Topics covered include measurement of adherence as a key issue in implementing any adherence intervention, GlowCap bottle as medication adherence measure, and Medication Event Monitoring System as a gold standard measure of medication adherence in trial settings.

Background: One in five older adults (age 65+) uses an antidepressant medication. However, little is known about how fall risk differs between commonly prescribed medications. We examine the comparative association between individual selective serotonin reuptake inhibitors (SSRI) and self‐reported falls in older adults. Methods: We used data from 2010–2017 Medicare Current Beneficiary Surveys, a nationally representative survey of Medicare beneficiaries. We included participants from three different panels surveyed over two successive years. Participants were limited to community‐dwelling Medicare beneficiaries 65+, enrolled in Medicare Part D, and taking an SSRI (n = 1023) during baseline years. Participants were asked about demographic and health characteristics, medication use (including dose, frequency, duration of use) and self‐reported falls as any fall or recurrent falls in the past year. We compared individual SSRI (citalopram or escitalopram vs sertraline) use by the average monthly total standardized daily dose (TSDD) and self‐reported falling, controlling for potential confounders. Descriptive analysis and multivariable logistic regressions were conducted using SAS‐callable SUDAAN. Results: Citalopram/escitalopram (n = 460 users; 45.0% of all SSRI users) and sertraline (n = 294 users; 28.7% of all SSRI users) were the most commonly prescribed SSRIs. Overall, 36.3% of citalopram/escitalopram users and 39.4% of sertraline users reported a fall in the year following medication use. There were no statistically significant differences between sertraline and citalopram/escitalopram users of either low or medium TSDD levels in the risk of self‐reported any or recurrent falls. However, users of high TSDD of sertraline (>75 mg) had a lower risk of recurrent falls compared to high TSDD citalopram (>30 mg) or escitalopram (>15 mg) daily for 30 days. Conclusion: These findings suggest a potential comparative safety benefit of sertraline compared to citalopram/escitalopram at high doses related to recurrent falls. Additional comparative studies of individual antidepressants may better inform fall risk management and prescribing for older adults. [ABSTRACT FROM AUTHOR]

A review of the article "Core Outcome Set for Trials Aimed at Improving Appropriate Polypharmacy in Older People in Primary Care" by A. Rankin, C.A. Cadogan, C. Ryan, et al., which appears in the same issue of the journal, is presented.

Objective: This study was undertaken to characterize trajectories of antiseizure medication (ASM) adherence in adults with newly treated epilepsy and to determine predictors of trajectories. Methods: This was a retrospective cohort study using Medicare. We included beneficiaries with newly treated epilepsy (one or more ASM and none in the preceding 2 years, plus International Classification of Diseases codes) in 2010–2013. We calculated the proportion of days covered (proportion of total days with any ASM pill supply) for 8 quarters or until death. Group‐based trajectory models characterized and determined predictors of trajectories. Results: We included 24 923 beneficiaries. Models identified four groups: early adherent (60%), early nonadherent (18%), late adherent (11%), and late nonadherent (11%). Numerous predictors were associated with being in the early nonadherent versus early adherent group: non‐White race (e.g., Black, odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.5–1.8), region (e.g., South vs. Northeast: OR = 1.2, 95% CI = 1.1–1.4), and once daily initial medication (OR = 1.1, 95% CI = 1.0–1.3). Predictors associated with decreased odds of being in the early nonadherent group included older age (OR =.9 per decade, 95% CI =.9–.9), female sex (OR =.9, 95% CI =.8–1.0), full Medicaid eligibility (OR =.6, 95% CI =.4–.8), neurologist visit (OR =.6, 95% CI =.6–.7), and initial older generation ASM (OR =.6, 95% CI =.6–.7). Significance: We identified four ASM adherence trajectories in individuals with newly treated epilepsy. Whereas risk factors for early nonadherence such as race or geographic region are nonmodifiable, our work highlighted a modifiable risk factor for early nonadherence: lacking a neurologist. These data may guide future interventions aimed at improving ASM adherence, in terms of both timing and target populations. [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: Detecting patients with undiagnosed dementia is an important clinical challenge. Changes in medication adherence might represent an early sign of cognitive impairment. We sought to examine antihypertensive and statin adherence trajectories in community-dwelling older adults, comparing people who went on to develop dementia to those who did not. Methods: We analyzed data from Adult Changes in Thought (ACT), a population-based cohort study embedded within an integrated healthcare delivery system. Analyses included 4368 participants aged ≥ 65 years who had at least one follow-up visit. Research-quality dementia diagnoses were used to identify cases. We selected non-dementia control visits matched on age, sex, and study cohort that occurred at similar ACT follow-up time as the case's dementia onset; we treated this as the index date. Participants were included if they were prevalent users of either a statin or antihypertensive medication on the first day of follow up -3 years prior to the index date. Using prescription fill dates and days supply, we calculated daily binary medication availability measures for each participant ('days covered') over 3 years leading up to the index date. We used group-based trajectory models to identify patterns of antihypertensive and statin adherence, and used conditional logistic regression to examine associations between adherence trajectories and dementia. Results: Four trajectories were identified for antihypertensive users (292 cases, 3890 control visits), including near perfect (n = 1877, 36.6% cases, 45.5% controls), high (n = 1840, 43.2% cases, 44.1 % controls), moderate (n = 365, 18.5% cases, 8.0% controls) and early poor adherence (n = 100, 1.7% cases, 2.4% controls). Odds of dementia was 3 times greater for those with moderate antihypertensive adherence compared to those with near perfect adherence (adjusted OR 3.0, 95% CI 2.0, 4.3). Four trajectories were identified for statin users (148 cases, 1131 control visits), including high (n = 1004, 75.0% cases, 79.0% controls), moderate (n = 192, 19.6% cases, 14.4% controls), early poor (n = 43, 2.0% cases, 3.5% controls), and delayed poor adherence (n = 40, 3.4% cases, 3.1 % controls). No association was detected between statin adherence trajectories and dementia. Conclusions: Patterns of medication adherence may be useful to identify a subset of people at higher likelihood of developing dementia. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented discussing a study on medication discrepancies and shared decision-making in the medical care of older adults.

A letter to the editor is presented which is concerned with topics which were discussed at a methodology workshop titled "Pills and Ills: Methodologic Issues in Pharmacologic Research" which was presented at the 2013 American Geriatrics Society Annual Scientific Meeting.

A response from the authors of the article "Medication Nonadherence: A Diagnosable and Treatable Medical Condition" in the 2013 issue is presented.