Potentially Inappropriate Medications Defined by STOPP Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients. Hamilton H, MB, Gallagher P, et al. The Archives of Internal Medicine 2011;171(June):1013-1019.
Background: Previous studies have not demonstrated a consistent association between potentially inappropriate medicines (PIMs) in older patients as defined by Beers criteria and avoidable adverse drug events (ADEs). This study aimed to assess whether PIMs defined by new STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) criteria are significantly associated with ADEs in older people with acute illness.
Methods: We prospectively studied 600 consecutive patients 65 years or older who were admitted with acute illness to a university teaching hospital over a 4-month interval. Potentially inappropriate medicines were defined by both Beers and STOPP criteria. Adverse drug events were defined by World Health Organization–Uppsala Monitoring Centre criteria and verified by a local expert consensus panel, which also assessed whether ADEs were causal or contributory to current hospitalization. Hallas criteria defined ADE avoidability. We compared the proportions of patients taking Beers criteria PIMs and STOPP criteria PIMs with avoidable ADEs that were causal or contributory to admission.
RESULTS: A total of 329 ADEs were detected in 158 of 600 patients (26.3%); 219 of 329 ADEs (66.6%) were considered causal or contributory to admission. Of the 219 ADEs, 151 (68.9%) considered causal or contributory to admission were avoidable or potentially avoidable. After adjusting for age, sex, comorbidity, dementia, baseline activities of daily living function, and number of medications, the likelihood of a serious avoidable ADE increased significantly when STOPP PIMs were prescribed (odds ratio, 1.847; 95% confidence interval [CI], 1.506-2.264; P<.001); prescription of Beers criteria PIMs did not significantly increase ADE risk (odds ratio, 1.276; 95% CI, 0.945-1.722; P=.11).
CONCLUSION: STOPP criteria PIMs, unlike Beers criteria PIMs, are significantly associated with avoidable ADEs in older people that cause or contribute to urgent hospitalization.
KEVINS COMMENTS: The Beers criteria refers to medications that are considered to be inappropriate when administered to older adults. The list was originally developed by Dr. Mark Beers, a geriatrician, and published in 1991 and updated in 2003. The medications included on the Beers list were associated with a higher risk of adverse effects to the physiological effects that occur with aging.
However, the criticism has been made that medicines on the Beers list have not consistently shown an association with adverse drug events. Another tool called the STOPP criteria (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) has been developed by a panel of European experts to screen for potentially inappropriate medications for the elderly. The panel was comprised of nine physicians in geriatric medicine, three clinical pharmacologists, two senior academic primary care physicians, one geriatric psychiatrist, and three senior hospital pharmacists with an interest in geriatric pharmacotherapy.
The criteria are organized by organ system. For example, under the cardiovascular system, the use of non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen in someone with congestive heart failure is deemed inappropriate. This study demonstrated that the STOPP criteria, unlike the Beers criteria, are associated with adverse drug events that result or contribute to urgent hospitalization.
Adverse drug events in the United States lead to more deaths than motor vehicle accidents, breast cancer, and HIV. Tools such as the STOPP riteria can be utilized to avoid potentially adverse drug events in older adults.
A Dimensional Analysis of Caregiver Burden Among Spouses and Adult Children. Savundranayagam MY, Montgomery RJ, Kosloski K: Gerontologist 2011;51 (June): 321-331.
Background: Caregiver burden is most often defined as a person’s emotional response to changes and demands that occur as they give help and support to a care recipient. The majority of caregivers are informal or unpaid caregivers, usually involving spouses and adult children. While there has been much research on this topic, few studies have focused on the dimensionality of caregiver burden and its impact on key outcomes.
Objective: To assess dimensions of caregiver burden in spouses and adult children.
Design: Cross-sectional study.
PARTICIPANTS: Study participants included 280 spousal and 243 adult child caregivers. Spousal caregivers were largely female (76%), white (91%), and ranged in age from 24 to 91 years (mean 63 years). In total, 53% had been providing care for their spouse for ≥5 years. Adult child caregivers were also largely female (88%) and white (77%), and ranged in age from 23 to 71 years (mean 52 years). Overall, 33% had provided care for a parent for 2 to 5 years, with an additional 36% providing care for ≥5 years. Care recipients’ average age was 67 years (spouse) and 81 years (parent).
Methods: Caregivers were recruited by staff members from >100 provider organizations in 6 states. Caregivers completed ≥1 questionnaires via mail (60%), telephone (4%), or online (36%). Measures included demographic information, assistance with activities of daily living (ADL), problem behaviors, caregiver burden, self-rated health, and intention to institutionalize.
RESULTS: The 3 dimensions of burden (stress, relationship, and objective) and all other model constructs were found to be equivalent for both spousal and adult child caregivers. Many other findings were found to be the same for both types of caregivers. Specifically, all 3 dimensions of burden were significantly associated with problem behavior, assistance with ADLs was significantly associated with objective burden, stress burden was significantly associated with self-rated health, and problem behaviors were significantly associated with intention to institutionalize.
The only differences found between the 2 groups related to burden dimension and intention to institutionalize were that stress burden was a significant predictor for spousal caregivers and relationship burden was a significant predictor for adult child caregivers.
CONCLUSION: Providers must be aware of the potential detrimental effects of caregiving on their patients’ emotional and physical health. This study demonstrates the importance of comprehensive assessment of caregiver burden in informal caregivers, including measurement of specific dimensions that will allow providers to provide individualized caregiver support.
KEVINS COMMENTS: There are currently over 50 million caregivers in the United States. Seventy-five percent are women. Caregivers typically experience stress, fatigue, and burnout. A significant number experience depression as a result of caregiving. Elderly spousal caregivers have a 63% higher risk of dying than non-caregivers.
Caregivers for those with dementia have a higher risk for dementia themselves. This study reinforces the importance of physician and health care provider awareness regarding the potential adverse health consequences of caregiving.
The importance of caregiver self-care must be emphasized. Caregivers often need to be given "permission" to nurture their mind, body, and spirit without feeling guilt about time taken away from a loved one.
Dry Mouth and Dietary Quality in Older Adults in North Carolina. Quandt SA, Savoca MR, et al. The Journal of the American Geriatric Society; 2011;59 (March): 439-445.
Objective: To describe the prevalence of dry mouth in an older population, and to examine the association between perceived dry mouth and fluid intake, dietary restrictions, and food modifications.
Design: Cross-sectional study from self-reported data.
PARTICIPANTS: 622 participants age ≥60 years from rural North Carolina.
Methods: Patients were surveyed using the 11-item Xerostomia Inventory to assess their perception of dry mouth burden. They were also surveyed using a food frequency questionnaire to determine dietary quality, and using a list of foods modified or avoided because of dry mouth.
RESULTS: Perceived dry mouth was associated with female gender, lower income level, and lower education level. Overall dietary quality did not change with perception of dry mouth, but those who reported dry mouth were more likely to avoid or modify foods due to their xerostomia symptoms.
CONCLUSION: The perception of xerostomia is a common condition in older adults, and can cause people who suffer from it to avoid or modify their diets. However, the perception of dry mouth does not seem to impact fluid intake or affect overall dietary quality.
KEVINS COMMENTS: Dry mouth (xerostomia) is a common condition in older adults that may have a significant adverse impact on nutrition, oral health, and quality of life. Although there are medical conditions that can cause dry mouth, such as diabetes and previous radiation to the head and neck, a side effect of medication is likely the most common reason. Diuretics, bladder control drugs, tricyclic antidepressants and antihistamines are commonly associated with dry mouth.
If dry mouth is causing adverse health effects or a negative impact on a person’s quality of life, an attempt should be made to reduce or withdraw those medications that are potentially contributing to the problem.
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