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Background: The Medicare Medication Therapy Management (MTM) program has been available to eligible Medicare Part D beneficiaries since 2006, but research regarding program utilization and characterization is limited., Objective: To describe enrollee and MTM program characteristics in a national sample of Medicare fee-for-service (FFS) beneficiaries (2013 to 2016)., Methods: Using a 5% random sample of Medicare FFS beneficiaries, we conducted a descriptive time series analysis to examine annual MTM enrollment and describe the type of MTM criteria at enrollment (Center for Medicare and Medicaid Services [CMS] vs. expanded). We investigated the offer of Comprehensive Medication Review (CMR) along with CMR receipt status, and delivery characteristics, as well as frequencies of Target Medication Reviews (TMRs)., Result: Beneficiaries who met CMS enrollment criteria, compared to those eligible under expanded criteria, were significantly older, more likely to be of white race, more likely to be female, and had a significantly higher number of comorbidities. Of those meeting CMS criteria, the proportion receiving TMR increased from 95% in 2013% to 98.1% in 2016, and over 97% were offered a CMR. Although the proportion of beneficiaries offered a CMR was stable over the study period, the proportion who received a CMR increased from 17% in 2013% to 35.4% in 2016. Telephone CMR delivery was the most common method used (87.8% to 89.1% of CMRs over the study period). Over 95% of the CMRs were delivered by a pharmacist., Conclusion: During the years 2013 to 2016, enrollment in the MTM program increased, as did the proportion of enrollees receiving TMRs and CMRs. However, uptake remained low and the main factors driving participation remain unclear. Significant differences in demographic characteristics between beneficiaries enrolled under the CMS MTM enrollment criteria and the expanded criteria suggest the need to further investigate the optimal provision of such programs., Competing Interests: Disclosure The author declares no conflicts of interest or financial interests in any product or service mentioned in this article., (Copyright © 2024 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Importance: Overactive bladder (OAB) is prevalent in older adults in whom management is complicated by comorbidities and greater vulnerability to the cognitive effects of antimuscarinic medications., Objectives: The aim of this study is to provide a comprehensive evidence-based summary of the 2021 State-of-the-Science (SOS) conference and a multidisciplinary expert literature review on OAB and cognitive impairment., Study Design: The American Urogynecologic Society and the Pelvic Floor Disorders Research Foundation convened a 3-day collaborative conference. Experts from multidisciplinary fields examined cognitive function, higher neural control of the OAB patient, risk factors for cognitive impairment in older patients, cognitive effects of antimuscarinic medications for OAB treatment, OAB phenotyping, conservative and advanced OAB therapies, and the need for a multidisciplinary approach to person-centered treatment. Translational topics included the blood-brain barrier, purine metabolome, mechanotransduction, and gene therapy for OAB targets., Results: Research surrounding OAB treatment efficacy in cognitively impaired individuals is limited. Short- and long-term outcomes regarding antimuscarinic effects on cognition are mixed; however, greater anticholinergic burden and duration of use influence risk. Oxybutynin is most consistently associated with negative cognitive effects in short-term, prospective studies. Although data are limited, beta-adrenergic agonists do not appear to confer the same cognitive risk., Conclusions: The 2021 SOS summary report provides a comprehensive review of the fundamental, translational, and clinical research on OAB with emphasis on cognitive impairment risks to antimuscarinic medications. Duration of use and antimuscarinic type, specifically oxybutynin when examining OAB treatments, appears to have the most cognitive impact; however, conclusions are limited by the primarily cognitively intact population studied. Given current evidence, it appears prudent to minimize anticholinergic burden by emphasizing nonantimuscarinic therapeutic regimens in the older population and/or those with cognitive impairment., Competing Interests: K.L.D. is a speaker (Education): Pacira, Inc. J.Z. received grant funding from Medtronic. A.W. is consultant and research support for Essity Hygiene & Health. Speaker bureau for Urovant Sciences. Research support for Pfizer Corp. C.E.DB. is part of the American Geriatric Society Beers Criteria Revision Panel. M.F.A.'s spouse is from Johnson & Johnson Corporate and received grant funding from National Institute on Aging, Alzheimer's Association, Tamara Harris Foundation. M.A. is part of MAB, Renovia, Inc. H.H.L. received grant funding from NIH, Medtronic: Interstim registry study, Neurspera: DSMB, Astella: Consultant, Ironwood, Biohaven, MicrogenDx: Consultant, V.W.S. received grant funding from NICHD. The remaining authors have declared that there are no conflicts of interest., (Copyright © 2023 American Urogynecologic Society. All rights reserved.)

The factors associated with chronic opioid therapy (COT) in patients with HIV is understudied. Using Medicaid data (2002-2009), this retrospective cohort study examines COT in beneficiaries with HIV who initiated standard combination anti-retroviral therapy (cART). We used generalized estimating equations on logistic regression models with backward selection to identify significant predictors of COT initiation. COT was initiated among 1014 out of 9615 beneficiaries with HIV (male: 10.4%; female: 10.7%). Those with older age, any malignancy, Hepatitis C infection, back pain, arthritis, neuropathy pain, substance use disorder, polypharmacy, (use of) benzodiazepines, gabapentinoids, antidepressants, and prior opioid therapies were positively associated with COT. In sex-stratified analyses, multiple predictors were shared between male and female beneficiaries; however, chronic obstructive pulmonary disease, liver disease, any malignancy, and antipsychotic therapy were unique to female beneficiaries. Comorbidities and polypharmacy were important predictors of COT in Medicaid beneficiaries with HIV who initiated cART., (© 2021. The Author(s).)

Background: Given the controversy around the effectiveness of opioid treatment for chronic pain and the lack of detailed guidance for prescribing opioids in older adults, the objectives of this study were to estimate the trajectories and predictors of opioid use in older adults., Methods: Data were extracted from the National Alzheimer's Coordinating Center (2005-2017). Group-based trajectory modeling was used to identify the patterns of opioid use (any or strong) among participants age 65+. We used multivariable logistic regression with backward selection to evaluate demographics and comorbidities as potential predictors of trajectory membership., Results: Among 13,059 participants, four trajectories were identified for the use of both any opioids and strong opioids (minimal-users, incident chronic-users, discontinuing-users, and prevalent chronic-users). For any opioids, female sex (adjusted odds ratio = 1.23; 95% confidence interval = 1.03-1.46), black vs. white (1.47; 1.18-1.82), year of education (0.96; 0.94-0.99), type of residence (independent group vs. private: 1.77; 1.38-2.26, care facility vs. private: 1.89; 1.20-2.97), hypertension (1.44; 1.20-1.72), cardiovascular disease (1.30; 1.09-1.55), urinary incontinence (1.45; 1.19-1.78), dementia (0.73; 0.57-0.92), number of medications (1 to 4 vs. none: 0.48; 0.36-0.64, 5 or more vs. none: 0.67; 0.50-0.88), and antidepressant agent (1.38; 1.14-1.67) were associated with incident chronic-use vs. non-use. For strong opioids, female sex (1.27; 1.04-1.56), type of residence (independent group vs. private: 1.90; 1.43-2.53, care facility vs. private: 2.37; 1.44-3.90), current smoking (1.68; 1.09-2.60), hypertension (1.49; 1.21-1.83), urinary incontinence (1.45; 1.14-1.84), dementia (0.73; 0.55-0.97), number of medications (1 to 4 vs. none: 0.46; 0.32-0.65, 5 or more vs. none: 0.59; 0.42-0.83), and antidepressant agent (1.55; 1.24-1.93) were associated with incident chronic-use vs. non-use., Conclusion: Given that chronic opioid use was more prevalent in participants who were more vulnerable (i.e., older age, with multiple comorbidities, and polypharmacy), further studies should evaluate the safety and efficacy of using opioids in this population., Competing Interests: The authors have declared that no competing interests exist.

ABSTRACTBackground:Longitudinal studies of older adults are characterized by high dropout rates, multimorbid conditions, and multiple medication use, especially proximal to death. We studied the association between multiple medication use and incident dementia diagnoses including Alzheimer's disease (AD), vascular dementia (VD), and Lewy-body dementia (LBD), simultaneously accounting for dropout., Methods: Using the National Alzheimer's Coordinating Center data with three years of follow-up, a set of covariate-adjusted models that ignore dropout was fit to complete-case data, and to the whole-cohort data. Additionally, covariate-adjusted joint models with shared random effects accounting for dropout were fit to the whole-cohort data. Multiple medication use was defined as polypharmacy (⩾ five medications), hyperpolypharmacy (⩾ ten medications), and total number of medications., Results: Incident diagnoses were 2,032 for AD, 135 for VD, and 139 for LBD. Percentages of dropout at the end of follow-up were as follows: 71.8% for AD, 81.5% for VD, and 77.7% for LBD. The odds ratio (OR) estimate for hyperpolypharmacy among those with LBD versus AD was 2.19 (0.78, 6.15) when estimated using complete-case data and 3.00 (1.66, 5.40) using whole-cohort data. The OR reduced to 1.41 (0.76, 2.64) when estimated from the joint model accounting for dropout. The OR for polypharmacy using complete-case data differed from the estimates using whole-cohort data. The OR for dementia diagnoses on total number of medications was similar, but non-significant when estimated using complete-case data., Conclusion: Reasons for dropout should be investigated and appropriate statistical methods should be applied to reduce bias in longitudinal studies among high-risk dementia cohorts.

Background: Use of potentially inappropriate medications (PIM) among people with dementia is common. We assessed the patterns of medication use from 1-year before dementia diagnosis, to 1-year after dementia diagnosis, compared with patterns of medication use in people without dementia., Methods: We conducted longitudinal study using the National Alzheimer's Coordinating Center data. Adults aged 65 years and older newly diagnosed with dementia (n = 2,418) during 2005-2015 were year, age, and sex matched 1:1 with controls. Generalized estimating equation models weighted for missingness and adjusted for 15 participant characteristics were fit., Results: Among participants with dementia, number of medications reported 1-year prediagnosis was 8% lower than at diagnosis year (p < .0001) and 11% higher 1-year postdiagnosis compared with year of diagnosis (p < .0001). Among participants with dementia, the odds of PIM exposure, assessed using the 2015 Beers Criteria, was 17% lower 1-year prediagnosis (p < .0001) and 17% higher 1-year postdiagnosis (p = .006) compared with year of diagnosis. Among controls, there were approximately 6% more medications reported between consecutive years (p < .0001 each comparison) and the odds of PIM exposure increased 11% between consecutive years (p = .006 and p = .047). At each annual follow-up, participants with dementia had lower odds of PIM exposure than their controls (prediagnosis p < .0001, at diagnosis p = .0007, postdiagnosis p = .03, respectively). There were no differences in exposure to anticholinergic medications., Conclusions: Number of medications and PIM use increased annually for participants with and without dementia. Persistent challenge of increasing PIM use in this group of older adults is of major concern and warrants interventions to minimize such prescribing.

Purpose: To estimate the risk of type II diabetes (T2DM) in children and adolescents initiating atypical antipsychotic (AAP) therapy., Methods: We conducted a retrospective cohort study using a new user design approach. Medical and pharmacy claims data between 1 January 2007 and 31 December 2009 for dependents ages 4 to 18 from an employed, commercially insured population from across the USA were included. AAP exposure was defined in the presence of a pharmacy claim preceded by at least six months of AAP-free history. We used propensity score (PS) methodology to identify and match incident AAP users and non-users. New-onset T2DM, was defined based on medical and pharmacy claims. Follow-up was extended until the date of new-onset T2DM or the end of the study period. The risk of T2DM was evaluated in an intent to treat fashion using the Kaplan-Meier estimator and Cox proportional hazard regression that provided hazard ratio (HR) and associated 95% confidence interval (CI)., Results: Our study population included 6236 new AAP users and 22 080 non-users. In this PS-matched sample, the estimated risk of T2DM was twice as high in AAP users as non-users (HR 2.18, 95% CI 1.45-3.29). Noticeable risk differences between AAP-treated and control groups materialized within four months of AAP initiation and became constant after six months until the end of the follow-up., Conclusions: Children and adolescents who were prescribed an AAP medication had a two times higher risk of developing T2DM; our study raises questions about continued AAP use in children and adolescents., (Copyright © 2015 John Wiley & Sons, Ltd.)

Objectives: To evaluate risks and benefits of bladder antimuscarinics (BAMs) among elderly long term care nursing home residents., Design: Retrospective cohort study using a new user design and propensity score matching., Setting: Veterans Affairs (VA) Community Living Centers (Nursing Homes)., Participants: Older adults (65 and older) admitted for long term care between October 1, 2002, and September 30, 2009., Measurements: The study used multiple VA data sources (Minimum Data Set [MDS], inpatient, outpatient, and pharmacy prescriptions administrative files). The following outcomes were evaluated: (1) fractures (hip fracture and "any" fracture) identified from inpatient and/or outpatient data (ICD-9-CM codes) and from MDS; (2) cognitive performance measured using the validated MDS Cognitive Performance Scale; (3) improvement in urinary incontinence measured from MDS; (4) quality of life measured from MDS using 2 validated instruments: Index of Social Engagement and Health Status Index. Covariates included demographic characteristics, baseline continence status (bladder and bowel) and continence management, preexistent urinary tract infections, body mass index, comorbidities, other medication use, cognitive status, and mobility at baseline. These variables were used to calculate the predicted probability (propensity score) of being initiated on a BAM; the resulting propensity scores were used to match new users and nonusers. Outcomes were compared with Cox proportional hazards regression and generalized estimating equations methodology., Results: BAMs were used by 9.8% of the residents 65 years and older admitted for long term care; 44% (1195) were new users. Of these, all but 53 received nonselective immediate release preparations, predominantly oxybutynin chloride (75%). BAM initiation resulted in improved urinary continence status (odds ratio = 1.27, 95% confidence interval [CI] 1.07-1.5) and better social engagement (difference in mean index of social engagement score = 0.2074, 95% CI 0.055-0.3598). The risk of fractures was significantly increased in new users as compared to nonusers (hip fracture: hazard ratio [HR] = 3.67, 95% CI 1.46-9.34; "any" fracture: HR = 2.64, 95% CI 1.37-5.10). The number needed to treat (NNT) to obtain improvement in urinary incontinence after 90 days of treatment (NNT = 32, 95% CI 17-125) was similar to the number needed to harm (NNH) at 90 days in the hip fracture analysis (NNH = 36, 95% CI 12-209). There were no differences in cognitive performance or overall quality of life scores associated with BAM use., Conclusion: These results question the continued use of BAMs, particularly immediate-release oxybutynin chloride in elderly nursing home residents., (Copyright © 2013 American Medical Directors Association, Inc. All rights reserved.)