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With ageing of the population worldwide and discovery of new medications for prevention and management of age-related conditions, there is increasing use of medications by older adults. There are international efforts to increase the representativeness of participants in clinical trials to match the intended real-world users of the medications across a range of characteristics including age, multimorbidity, polypharmacy and frailty. Currently, much of the data on medication-related harm in older adults are from pharmacovigilance studies. New methods in pre-clinical models have allowed for measurement of exposures (such as chronic exposure, polypharmacy and deprescribing) and outcomes (such as health span functional measures and frailty) that are highly relevant to geriatric pharmacotherapy. Here we describe opportunities for design and implementation of pre-clinical models that can better predict drug effects in geriatric patients. This could improve the translation of new drugs from bench to bedside and improve outcomes of pharmacotherapy in older adults. [ABSTRACT FROM AUTHOR]

Background: Behavioral and psychological symptoms of dementia are commonly treated with antipsychotic drugs (APDs), which have been associated with adverse health effects. We examine the effect of APDs on long-term care (LTC), nursing home (NH) admission, and death of dementia patients.Methods: We used health claims data of the largest German health insurer from 2004 to 2010 and followed newly-diagnosed dementia patients aged 60 years and older into LTC, NH, and until death. Cox proportional hazards models were estimated to explore whether the risk of these outcomes differed between patients receiving haloperidol, melperone, risperidone, or quetiapine.Results: In a cohort of 6,930 dementia patients who were initially free of LTC dependency, APD users generally faced a twofold increased risk of LTC relative to nonusers. Quetiapine was the exception, showing a comparatively lower risk (HR = 1.64; CI = 1.35-1.98). Among 9,950 dementia patients initially living in private homes, the risk of moving into a NH was generally increased by about 50% among APD users relative to nonusers. Risk of death (N = 10,921) was significantly higher for haloperidol-, melperone-, and risperidone- but not for quetiapine users (HR = 0.91; CI = 0.78-1.08). The excess mortality associated with haloperidol and melperone was greater among patients living in private households.Conclusions: In our study, APDs appeared to accelerate adverse health outcomes in German dementia patients. Differentiating between the effect of antipsychotic drug use among dementia patients residing in private households and in NHs, we found that excess mortality for haloperidol and melperone users was higher in private settings. [ABSTRACT FROM AUTHOR]

Objective The aim of this study is to systematically review the scientific literature to investigate if use of antiepileptic drugs (AEDs) is associated with falls and/or recurrent falls in old age. Method We searched the literature for relevant articles in PubMed and Embase published up until 3rd December 2015. Studies on people aged 60 years and over with an observational design assessing the risk of fall in people exposed to AEDs compared to people not exposed to AED were included. Results We found 744 studies by searching Medline and Embase and an additional 9 studies by reviewing relevant reference lists. Of these studies, 13 fulfilled our predefined criteria. The articles were of various study design, sizes and follow-up times, and presented the results in different ways. Also, confounder adjustment varied considerably between the studies. Ten studies presented results for the association between use of any AED and any fall/injurious fall. Of these studies, 6 presented adjusted estimates, of which all but one showed statistically significant associations between use of any AED and any fall/injurious fall. Six studies investigated the association between use of any AED and recurrent falls. Of these, only 3 studies presented adjusted effect estimates of which 2 reached statistical significance for the association between use of AEDs and recurrent falls in elderly people. Conclusion Our results indicate an association between use of AEDs and risk of falls and recurrent falls in older people. This finding may be clinically important given that a substantial amount of older people use these drugs. However, further research is needed to increase the knowledge about the actual risk of falls when using these drugs in old age. [ABSTRACT FROM AUTHOR]

Aims: To investigate the development of healthy life expectancy from 65 years (HLE65) in Sweden in the period 1980–2011 using the health indicators activities of daily living (ADL) and mobility limitations within the framework of the postponement, compression and expansion theories. Methods: Sources of data for the HLE computations were Swedish national mortality statistics and the nationwide Swedish Surveys of Living Conditions, conducted biennially by Statistics Sweden since 1974. We used the Sullivan method for calculations of HLE and a decomposition into mortality and disability effects was made. Results: Life expectancy at age 65 (LE65) increased by 3.1 years for women and 4.0 years for men from 1980–1985 to 2006–2011. HLE65 calculated according to ADL and mobility limitations increased more rapidly than LE65 for both men and women (p<0.05). Conclusions: Our results for trends in the Swedish LE65 and HLE65, computed on the basis of ADL and mobility limitations and using the Swedish Surveys of Living Conditions study, are in line with the postponement hypothesis and there is also a tendency for compression. Thus the years with ADL dependence and mobility limitations are postponed to a higher age and the numbers of these years have decreased. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether psychotropics are associated with an increased risk of fall injuries, hospitalizations, and mortality in a large general population of older adults.Methods: We performed a nationwide matched (age, sex, and case event day) case-control study between 1 January and 31 December 2011 based on several Swedish registers (n = 1,288,875 persons aged ≥65 years). We used multivariate conditional logistic regression adjusted for education, number of inpatient days, Charlson co-morbidity index, dementia and number of other drugs.Results: Antidepressants were the psychotropic most strongly related to fall injuries (ORadjusted : 1.42; 95% CI: 1.38-1.45) and antipsychotics to hospitalizations (ORadjusted : 1.22; 95% CI: 1.19-1.24) and death (ORadjusted : 2.10; 95% CI: 2.02-2.17). Number of psychotropics was associated with increased the risk of fall injuries, (4 psychotropics vs 0: ORadjusted : 1.53; 95% CI: 1.39-1.68), hospitalization (4 psychotropics vs 0: ORadjusted : 1.27; 95% CI: 1.22-1.33) and death (4 psychotropics vs 0: ORadjusted : 2.50; 95% CI: 2.33-2.69) in a dose-response manner. Among persons with dementia (n = 58,984), a dose-response relationship was found between number of psychotropics and mortality risk (4 psychotropics vs 0: ORadjusted : 1.99; 95% CI: 1.76-2.25).Conclusions: Our findings support a cautious prescribing of multiple psychotropic drugs to older patients. © 2016 The Authors. International Journal of Geriatric Psychiatry Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: discussing end-of-life issues with nursing home residents and their relatives is needed to ensure patient-centred care near the end of life. Objectives: this study aimed to estimate the frequency of nursing home physicians discussing end-of-life issues with residents and their relatives and to investigate how discussing end-of-life issues was associated with care outcomes in the last month of life. Methods: post-mortem cohort study in a nationwide, representative sample of 78 nursing home facilities in France. Residents who died from non-sudden causes between 1 October 2013 and 31 May 2014 in these facilities were included (n = 674). Results: end-of-life issues were discussed with at most 21.7% of the residents who died during the study period. In one-third of the situations (32.8%), no discussion about end-of-life-related topics ever occurred, either with the resident or with the relatives. Older people with severe dementia were less likely to have discussed more than three of the six end-of-life topics we investigated, compared with residents without dementia (OR = 0.17, 95% CI = 0.08--0.22). In the last month of life, discussing more than three end-of-life issues with the residents or their relatives was significantly associated with reduced odds of dying in a hospital facility (adjusted OR = 0.51, 95% CI = 0.33--0.79) and with a higher likelihood of withdrawing potentially futile life-prolonging treatments (adjusted OR = 2.37, 95% CI = 1.72-3.29). Conclusion: during the last months of life, discussions about end-of-life issues occurred with only a minority of nursing home decedents, although these discussions may improve end-of-life care outcomes. [ABSTRACT FROM AUTHOR]

New drugs and expanded drug indications are constantly being introduced. Welfare states strive to provide equity in drug treatment for all of its citizens and todaýs healthcare systems spend financial resources on drugs for the elderly in a higher rate than for any other age group. Drug utilization in elderly persons has an impact in health and wellbeing in older people. The purpose of the research It was to describe the changes in medication use including people aged 78 years and over regardless of residence and other characteristics over 20 years. Materials and methods The study population consisted of 4304 participants in three population-based cross-sectional surveys conducted in the Kungsholmen area of central Stockholm, Sweden. The participant’s current drug utilization was reviewed by physicians following standardized protocols. Data were statistical analyzed. Logistic regression models was used to estimate odds ratios and 95% confidence intervals for use of analgesics and psychotropic drugs in the cohorts of 2001 and 2007, controlling for age, gender, education and cognition. The principal results and major conclusions Results shows that the prevalence of medication use and polypharmacy in older adults has increased dramatically the late 1980s to the 2000s in central Stockholm, Sweden. In particular, the use of analgesics increased significantly, while some drug groups decreased, i.e., antipsychotics. Women used more medication than men in all three cohorts. Older adults living in service buildings used the largest amount of drugs in 1987, whereas those living in institutions were the most frequent users in 2001 and 2007. [ABSTRACT FROM AUTHOR]

Aims: To investigate the development of healthy life expectancy from 65 years (HLE65) in Sweden in the period 1980 and 2010 by using two different health indicators: self-rated health and the global activity limitation indicator (GALI). Methods: Sources of data for the HLE computations were Swedish national mortality statistics and the nationwide Swedish Survey of Living Conditions (SSLC), which have been conducted biennially by Statistics Sweden since 1974. We used the Sullivan method for calculations of HLE. A decomposition into mortality and disability effect has been made in accordance with the method devised by Nusselder. Results: Life expectancy at age 65 (LE65) increased by 3.1 years for women and 4.0 years for men from 1980/85 to 2006/11. Regardless of which health measure investigated – self-rated health or GALI – HLE65 increased between the periods 1980/85 to 2006/2011 more rapidly than LE65 and as a consequence the years with bad self-rated health and years with activity limitations decreased. These increases as well as the decreases were significant (p<0.05). Conclusions: The Swedish LE65 and HLE65 development, as judged by the SSLC study, are compatible with the postponement hypothesis and there is even a clear tendency for compression. Thus, the years with bad self-rated health and years with activity limitations are postponed to a higher age and the number of those years have decreased. From this respect, the Swedish development looks positive. The need of old age care in 2010 would have been much higher if it had been expansion – not postponement – of bad self-rated health and years with activity limitations during the time period. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular diseases are leading causes of death and patients with dementia are often affected by them.Objective: Investigate associations of cardiovascular diseases with different dementia disorders and determine their impact on mortality.Methods: This study included 29,630 patients from the Swedish Dementia Registry (mean age 79 years, 59% women) diagnosed with Alzheimer's disease (AD), mixed dementia, vascular dementia, dementia with Lewy bodies (DLB), Parkinson's disease dementia (PDD), frontotemporal dementia (FTD), or unspecified dementia. Records of cardiovascular diseases come from the Swedish National Patient Register. Multinomial logistic regression and cox proportional hazard models were applied.Results: Compared to AD, we found a higher burden of all cardiovascular diseases in mixed and vascular dementia. Cerebrovascular diseases were more associated with DLB than with AD. Diabetes mellitus was less associated with PDD and DLB than with AD. Ischemic heart disease was less associated with PDD and FTD than AD. All cardiovascular diseases predicted death in patients with AD, mixed, and vascular dementia. Only ischemic heart disease significantly predicted death in DLB patients (HR = 1.72; 95% CI = 1.16-2.55). In PDD patients, heart failure and diabetes mellitus were associated with a higher risk of death (HR = 3.06; 95% CI = 1.74-5.41 and HR = 3.44; 95% CI = 1.31-9.03). In FTD patients, ischemic heart disease and atrial fibrillation or flutter significantly predicted death (HR = 2.11; 95% CI = 1.08-4.14 and HR = 3.15; 95% CI = 1.60-6.22, respectively).Conclusion: Our study highlights differences in the occurrence and prognostic significance of cardiovascular diseases in several dementia disorders. This has implications for the care and treatment of the different dementia disorders. [ABSTRACT FROM AUTHOR]

Aim: To investigate the associations between medication use and functional dependence in Chinese older people living in a rural community. Methods: The cross-sectional study included 1538 participants (age ≥60 years, 59.1% women) in the Confucius Hometown Aging Project in Shandong, China. In June 2010 to July 2011, data on demographics, lifestyle factors, health history, basic activities of daily living (ADL), instrumental ADL, and use of medications were collected through interviews and clinical examinations. Functional status was categorized into no dependence, dependence only in instrumental ADL and dependence in basic ADL. Data were analyzed with multinomial logistic models controlling for potential confounders. Results: Dependence in instrumental or basic ADL was significantly associated with use of antihypertensives and hypolipidemic agents, and basic ADL dependence was also associated with use of sedatives or tranquilizers and cardiac glycosides. An increased number of concurrently used medications was significantly associated with an increased likelihood of dependence in basic ADL (P for trend = 0.016). Compared with non-users of any medication, individuals who concurrently used three or more classes of medications had a multi-adjusted odds ratio of 2.91 (95% confidence interval 1.02-8.28) for dependence in basic ADL. Conclusions: Use of antihypertensives, hypolipidemic drugs, cardiac glycosides and sedatives or tranquilizers, especially use of multiple classes of medications, is correlated with functional dependence among older people in rural China. [ABSTRACT FROM AUTHOR]

Purpose: There is a lack of population-based research about factors associated with medication regimen complexity. This study investigated factors associated with medication regimen complexity in older people, and whether factors associated with regimen complexity were similar to factors associated with number of medications. Methods: This cross-sectional population-based study included 3348 people aged ≥60 years. Medication regimen complexity was computed using the validated 65-item Medication Regimen Complexity Index (MRCI). Multinomial logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) with 95 % confidence intervals (CIs) for factors associated with regimen complexity. Multivariable quantile regression was used to compare factors associated with regimen complexity and number of medications. Results: In adjusted analyses, participants in the highest MRCI quintile (MRCI > 20) were older (OR = 1.04, 95 % CI 1.02;1.05), less likely to live at home (OR = 0.35, 95 % CI 0.15;0.86), had greater comorbidities (OR = 2.17, 95 % CI 1.89;2.49), had higher cognitive status (OR = 1.06, 95 % CI 1.01;1.11), a higher prevalence of self-reported pain (OR = 2.85, 95 % CI 2.16;3.76), had impaired dexterity (OR = 2.39, 95 % CI 1.77;3.24) and were more likely to receive help to sort their medications (OR = 4.43 95 % CI 2.39;8.56) than those with low regimen complexity (MRCI >0-5.5). Similar factors were associated with both regimen complexity and number of medications. Conclusion: Older people with probable difficulties managing complex regimens, including those with impaired dexterity and living in institutional settings, had the most complex medication regimens even after adjusting for receipt of help to sort medications. The strong correlation between regimen complexity and number of medications suggests that clinicians could use a person's number of medications to target interventions to reduce complexity. [ABSTRACT FROM AUTHOR]

Objectives: recent studies have reported that hospitals have become a common place of death for nursing home residents. This study aimed to (i) measure variations in the proportion of in-hospital deaths across regions after adjustment for facility-level characteristics and (ii) identify environmental risk factors that might explain these variations in France. Design: a cross-sectional retrospective survey was conducted in 2013. Setting and participants: coordinating physicians in 3,705 nursing homes in France. Measurements: a regression model was used to construct risk-adjusted rates of in-hospital deaths considering the facilities' characteristics. At the regional level, the outcome was defined as the difference between the observed rate of in-hospital deaths and the expected risk-adjusted rate. Values exceeding zero indicated rates that exceeded the national predicted rate of in-hospital deaths and thus highlighted regions in which the risk-adjusted probability for nursing home residents to die in a hospital was greater than average. Results: among 70,119 nursing home decedents, 25.4% (n = 17,789) died in hospitals. The characteristics of the facilities had a significant influence on the proportion of in-hospital deaths among the nursing home decedents. However, after adjustment for these facility-level risk factors, the proportion of nursing homes that reported worse-than-average outcomes showed significant variation (range 26.0-79.6%). At the regional level, both the rate of acute hospital beds and the rate of general practitioners were found to be strongly correlated with the probability of reporting worse-than-average outcomes (P < 0.001). Conclusion: our study demonstrates the existence of major differences across regions in France and highlights the need for targeted interventions regarding end-of-life care in nursing home facilities. [ABSTRACT FROM AUTHOR]

Objectives: recent studies have reported that hospitals have become a common place of death for nursing home residents. This study aimed to (i) measure variations in the proportion of in-hospital deaths across regions after adjustment for facility-level characteristics and (ii) identify environmental risk factors that might explain these variations in France. Design: a cross-sectional retrospective survey was conducted in 2013. Setting and participants: coordinating physicians in 3,705 nursing homes in France. Measurements: a regression model was used to construct risk-adjusted rates of in-hospital deaths considering the facilities' characteristics. At the regional level, the outcome was defined as the difference between the observed rate of in-hospital deaths and the expected risk-adjusted rate. Values exceeding zero indicated rates that exceeded the national predicted rate of in-hospital deaths and thus highlighted regions in which the risk-adjusted probability for nursing home residents to die in a hospital was greater than average. Results: among 70,119 nursing home decedents, 25.4% (n = 17,789) died in hospitals. The characteristics of the facilities had a significant influence on the proportion of in-hospital deaths among the nursing home decedents. However, after adjustment for these facility-level risk factors, the proportion of nursing homes that reported worse-than-average outcomes showed significant variation (range 26.0-79.6%). At the regional level, both the rate of acute hospital beds and the rate of general practitioners were found to be strongly correlated with the probability of reporting worse-than-average outcomes (P < 0.001). Conclusion: our study demonstrates the existence of major differences across regions in France and highlights the need for targeted interventions regarding end-of-life care in nursing home facilities. [ABSTRACT FROM AUTHOR]

Inappropriate drug use is an important health problem in elderly persons. Beginning with the Beers' criteria in the early 1990s, explicit criteria have been extensively used to measure and improve quality of drug use in older people. This article describes the Swedish indicators for quality of drug therapy in the elderly, introduced in 2004 and updated in 2010. These indicators were designed to be applied to people aged 75 years and over, regardless of residence and other characteristics. The indicators are divided into drug specific, covering choice, indication and dosage of drugs, polypharmacy, drug-drug interactions (DDIs), drug use in decreased renal function and in some symptoms; and diagnosis specific, covering the rational, irrational and hazardous drug use in common disorders in elderly people. During the 10 years since introduction, the Swedish indicators have several applications. They form the basis for recommendations for drug therapy in older people, are implemented in prescribing supports and drug utilisation reviews, are used in national benchmarking of the quality of Swedish healthcare and have contributed to initiatives from pensioner organisations. The indicators have also been used in several pharmacoepidemiological studies. Since 2005, there have been signs of improvement of the quality of drug prescribing to elderly persons in Sweden. For example, the prescribing of drugs that should be avoided in older persons decreased by 36 % between 2006 and 2012 in persons aged 80 years and older. Similarly, drug combinations that may cause DDIs decreased by 26 % and antipsychotics by 41 %. The indicators have likely contributed to this. [ABSTRACT FROM AUTHOR]

Background: There is a substantial risk of drug-interactions, adverse events, and inappropriate drug use (IDU) among frail Alzheimer's disease (AD) patients; however, there are few studies about co-medication and IDU in clinical settings. Objectives: To investigate anti-dementia drugs, associated characteristics of cholinesterase inhibitors (ChEIs) and NMDA antagonists, co-medication, and IDU in a large population of outpatients with mild AD. Methods: In this cross-sectional analysis of medication characteristics, we analyzed data from the Swedish Dementia Quality Registry (SveDem) on 5,907 newly diagnosed AD patients who were registered in memory clinics. SveDem is a national quality registry in Sweden, which was established in 2007 to evaluate and improve dementia healthcare. Comparisons were performed concerning co-medications, use of ≥3 psychotropic drugs (IDU) and polypharmacy (≥5 drugs) based on anti-dementia treatment (ChEIs or NMDA antagonists). Information on baseline characteristics such as age, sex, living conditions, cognitive evaluation based on the Mini-Mental State Examination (MMSE) score, and diagnostic work-up was also evaluated. Results: The majority of the AD patients were in the mild stage of the disease. Overall, 4,342 (75.4 %) patients received any ChEI, 438 (7.6 %) used an NMDA antagonist and 74 (1.3 %) patients were treated with both. However, 907 (15.7 %) patients were not treated with any anti-dementia drug. While polypharmacy was seen in 33.5 % of patients, only 2.6 % concurrently used ≥3 psychotropic medications. Patients on ChEIs were significantly younger, had a higher MMSE score and were treated with a smaller number of medications (a proxy for overall co-morbidity). Co-medication with antipsychotics [3.3 vs. 7.6 %; adjusted odds ratio (OR) 0.55 (95 % CI 0.38-0.79)] and anxiolytics [5.8 vs. 10.9 %; adjusted OR 0.62 (95 % CI 0.46-0.84)] was significantly lower in the ChEI+ group than in those with no anti-dementia treatment. Conclusion: Patients taking ChEIs were treated with less antipsychotics and anxiolytics than those not taking ChEIs. More research is warranted to elucidate whether use of ChEIs in clinical practice can reduce the need for psychotropic drugs in AD patients. [ABSTRACT FROM AUTHOR]

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

Background: Among senior drivers, benzodiazepines (BZDs) have a documented effect on the risk of road traffic crashes (RTCs). It remains unclear however if BZDs play the same role when considering marital status. Therefore, we aimed to investigate the role of marital status in the association between BZD use and injurious RTCs among senior drivers. Methods: Matched case-control study based on five national Swedish registers (n = 154 225). Cases comprised the first non-alcohol-related injurious RTC sustained by drivers aged 50–80 years from July 2005 to December 2009 and controls included registered residents with a valid license who did not crash during that period. Four controls were matched to each case by sex, age and place of residence. Conditional logistic regression analysis for injurious RTC was performed with adjustment for occupation and number of medications. The main exposure was dispensation of BZDs, alone or in combination with other psychotropic medications, 1–30 days prior to the crash date stratified by marital status. Results: BZD use, alone or in combination with other psychotropic medications, increased the risk of being involved in an RTC (BZD only: adjusted OR: 1.26, 95% CI: 1.17–1.36; BZDs and other psychotropics: adjusted OR: 1.25, 95% CI: 1.12–1.41). Compared to married drivers, those divorced (1.48, 1.43–1.53) and widowed (1.54; 1.45–1.63) had higher adjusted ORs. Marital status modified the association between BZDs and RTCs, particularly among younger male drivers. Conclusions: Both BZDs and marital status independently affect the risk for senior drivers to be involved in an RTC. However, marital status plays a role in the association between BZD use and RTCs and this may have implications for targeting risk populations for RTCs among senior drivers. [ABSTRACT FROM AUTHOR]

This clinical review summarizes the evidence in relation to clinical outcomes from drug-drug and drug-disease interactions in older people., Exposure to drug-drug interactions is associated with increased risk of hospitalization-related outcomes in older people. Drug-disease interactions have been linked with adverse drug interactions and adverse drug events in studies of older people., Although the prevalence of drug-drug and drug-disease interactions is common in older people, there are very limited empirical data on important clinical outcomes from drug-drug and drug-disease interactions., Clinical implications of interactions between drugs and geriatric syndromes such as frailty, falls, cognitive impairment, immobility and urinary incontinence should also be considered in older people. [ABSTRACT FROM AUTHOR]

Background/Aims: We aimed to study whether there are differences between dementia disorders and the use of anti-dementia drugs and antipsychotics (neuroleptics) in a large population of dementia patients. Methods: Information about dementia disorders was obtained from the national Swedish Dementia Registry (SveDem) 2007-2010 (n = 7,570). Multivariate logistic regression analysis was performed to investigate the association between dementia disorders and the use of anti-dementia drugs and antipsychotics, after adjustment for age, sex, residential setting, living alone, MMSE score and number of other drugs (a proxy for overall co-morbidity). Results: More than 80% of the Alzheimer's disease (AD) and 86% of dementia with Lewy bodies (DLB) patients used anti-dementia drugs. Women were more likely than men to be treated with cholinesterase inhibitors. A higher MMSE score was positively associated with the use of cholinesterase inhibitors, but negatively associated with NMDA receptor antagonists and antipsychotics. Use of antipsychotics was 6% overall; however, it was 16% in DLB patients with an adjusted odds ratio of 4.2 compared to AD patients. Conclusion: Use of anti-dementia drugs in AD was in agreement with Swedish guidelines. However, use of antipsychotics in DLB patients was high, which might be worrying given the susceptibility of DLB patients to antipsychotics. Copyright © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Purpose: It is largely unknown how the medical treatment of patients diagnosed with dementia is followed up in primary care. Therefore, we studied patient medical records from two dementia clinics and from the referring primary care centres. Methods: A retrospective study of 241 patients was conducted from April to October 2011 in north west Stockholm, Sweden. Over half (51.5%) of the patients had Alzheimer’s disease (AD), the remainder had mixed AD/vascular dementia (VaD). Eighty-four medical reports from primary care (35% of the study group) were analysed at follow-up 18 months after diagnosis. Results: All four dementia drugs available on the Swedish market (three cholinesterase inhibitors [donepezil, rivastigmine and galantamine] and memantine) were prescribed at the two dementia clinics. The most commonly used dementia drug was galantamine. There were differences between the two dementia clinics in preference and combination of drugs and of treatment given to male and female patients. At follow-up, 84% were still on dementia medication. Drug use was followed up by the general practitioners (GPs) in two-thirds of the cases. Eighteen per cent of the GPs’ medical records made no reference to the patient’s dementia or treatment even though dementia drugs were included in the list of medications prescribed. Conclusions: The results indicate that the Swedish guidelines for treatment of cognitive symptoms in AD are being followed in primary care. However, documentation of follow-up of drug treatment was sometimes insufficient, which calls for development of guidelines for complete medical records and medication lists. [ABSTRACT FROM AUTHOR]

Background Most previous studies about drug use in the elderly population have either investigated drug use in institutions or in the community-dwelling setting. Hence, very few studies have compared drug use in institutionalized and community-dwelling elderly, maybe because of a lack of sufficiently large databases. Objective The aim of the study was to investigate differences in drug use patterns between community-dwelling and institutionalized elderly, after adjustment. for age, gender and number of other drugs (used as a proxy for overall co-morbidity). Methods We analysed data from individuals aged ≥65 years who filled at least one drug prescription between July and September 2008 and were consequently registered in the Swedish Prescribed Drug Register (n = 1,347,564; 1,260,843 community-dwelling and 86,721 institutionalized elderly). A list of current prescriptions was constructed for every individual on the arbitrarily chosen date 30 September 2008. Outcome measures were the 20 most common drug classes and the 20 most common individual drugs. Logistic regression analysis was used to investigate whether institutionalization was associated with use of these drugs, after adjustment for age, gender and number of other drugs. Results Institutionalized elderly were more likely than community-dwelling elderly to use antidepressants, laxatives, minor analgesics, opioids and hypnotics/seda- tives, after adjustment for age, gender and number of other drugs. On the contrary, institutionalization was negatively associated with use of lipid modifying agents, angiotensin II antagonists, selective calcium channel blockers, β-blocking agents and ACE inhibitors, after adjustment for age, gender and number of other drugs. Conclusions Our results indicate that institutionalized elderly are more likely than community-dwelling elderly to use psychotropics, analgesics and laxatives, but less likely to receive recommended cardiovascular drug therapy, which may indicate a need for implementation of evidence- based guidelines for drug treatment in this vulnerable group of elderly patients. Further research is needed to elucidate to what extent the differences in drug use between community-dwelling and institutionalized elderly are explained by different underlying disease patterns and by different prescribing traditions in the different settings. [ABSTRACT FROM AUTHOR]

Purpose: To investigate whether institutionalization is associated with the use of antiepileptic drugs (AEDs) and to compare the association between use of AEDs and psychotropics in community-dwelling and institutionalized elderly, after adjustment for age, sex and co-morbidity (i.e. number of other drugs). Methods: We analyzed data on age, sex and dispensed drugs for individuals aged ≥65 years registered in the Swedish Prescribed Drug Register from July to September 2008, record-linked to the Swedish Social Services Register ( n = 1 345 273: 1 258 565 community-dwelling and 86 708 institutionalized elderly). Multivariate logistic regression analysis was used to analyze whether institutionalization and use of psychotropics (i.e. antipsychotics, anxiolytics, hypnotics/sedatives and antidepressants) were associated with the use of AEDs. Results: AEDs were used by 2% of the community-dwelling and 9% of the institutionalized elderly. The most commonly used AEDs were carbamazepine, gabapentin, pregabalin, valproic acid and lamotrigine. Institutionalization was strongly associated with AED use (OR = 3.98; 95% CI 3.86-4.10). In community-dwelling elderly, AED use was associated with an increased probability of use of all types of psychotropics. However, among institutionalized elderly, the associations between use of AEDs and psychotropics showed a mixed pattern. Conclusions: AED use seems to be common among Swedish institutionalized elderly, and institutionalization is a strong determinant of AED use. Our results may also indicate an off-label prescribing of AEDs as an alternative to psychotropics in the institutional setting. This finding needs to be confirmed by others and evaluated with respect to outcomes of this treatment in institutionalized elderly. [ABSTRACT FROM AUTHOR]

Background and objective. The number of elderly persons in society is increasing, placing additional demands on the public health system. Extensive use of drugs is common in the elderly, and in patients with dementia this further increases their vulnerability. Since 1998 the municipality of Kalmar, Sweden, has worked with a dementia management programme that focuses on early intervention in order to identify the patient's help needs at an early stage. An important part of the programme aims at optimizing pharmacological treatment. The objective of the present study is to evaluate whether the dementia programme had a secondary effect on the use of psychotropic medication in the elderly population in general. Design and setting. A retrospective, drug utilization study analysing the use of selected drug categories by the elderly (75 years and older) in the Kalmar municipality compared with the whole of Sweden. Results and conclusions. The results suggest that the dementia programme contributed to an improvement in psychotropic drug use in the elderly as a secondary effect. Furthermore, the implementation of this programme did not require allocation of extra funding. [ABSTRACT FROM AUTHOR]

Objective: To investigate the use of dopaminergic and serotonergic drugs in elderly people Methods: We analyzed data on age, sex and dispensed drugs for individuals aged &ges;65 years registered in the Swedish Prescribed Drug Register from July to September 2008 (n = 1 347 564; 81% of the total population aged &ges;65 years in Sweden). Main outcome measures were dopaminergic (enhancing and/or lowering) and serotonergic (enhancing and/or lowering) drugs and combinations of these Results: Dopaminergic and serotonergic drugs were used by 5.6% and 13.2% the participants, respectively. Female gender was related to use of both dopaminergic and, particularly, serotonergic drugs. Higher age was associated with use of dopamine lowering drugs and serotonergic drugs, whereas the association with use of dopamine enhancing drugs declined in the oldest old. The occurrence of combinations of dopaminergic and serotonergic drugs was generally low, with dopamine lowering + serotonin lowering drug the most common combination (1.6%). Female gender was associated with all of the combinations of dopaminergic and serotonergic drugs, whereas age showed a mixed pattern. Conclusion: Approximately one out of ten older patients uses serotonergic drugs and one out of twenty dopaminergic drugs. The frequent use of dopaminergic and serotonergic drugs in the elderly patients is a potential problem due to the fact that aging is associated with a down-regulation of both these monoaminergic systems. Future studies are needed for evaluation of the impact of these drugs on different cognitive and emotional functions in old age. [ABSTRACT FROM AUTHOR]

Objective To determine the factors associated with use of benzodiazepines and benzodiazepine related drugs (BZDs/BZDRDs) in a nationwide population of older people. Methods We analyzed data on age, sex, type of residential area (urban/rural), and dispensed drugs for people aged ≥ 75 years registered in the Swedish Prescribed Drug Register from October to December 2005 (n = 731 105; corresponds to 91% of the domain population). Multivariate logistic regression analysis was used for analyzing whether age, sex, type of residential area, number of other drugs, and concomitant psychotropic drug use was associated with use of BZDs/BZDRDs. Results ≥1 BZDs/BZDRDs and ≥2 BZDs/BZDRDs were used by 25% and 5% of the study population, respectively. The most commonly used BZDs/BZDRDs were zopiclone, zolpidem, oxazepam, flunitrazepam, and diazepam. The probability of use BZDs/BZDRDs increased with age, female gender, living in an urban area, use of many other drugs, and concomitant use of other psychotropics, particularly antidepressants. In the comparisons of different BZDs/BZDRDs (n = 179 632), the medium-acting BZDs were associated with higher age, female gender, and use of other psychotropics, whereas BZDRDs showed the opposite pattern. Also, the two BZDRDs zopiclone and zolpidem showed different patterns regarding age, sex, and use of other drugs. Conclusions One in four of the elderly used one or more BZD/BZDRD, which should be prescribed cautiously and with the recognition of the potentially negative effects. There were differences in patterns of use for different BZDs/BZDRDs, even within the same drug class. Hence, large study populations are needed for future research of individual BZDs/BZDRDs. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To investigate whether low educational attainment is associated with polypharmacy and potential inappropriate drug use (IDU) in older people. DESIGN: Cross-sectional register-based study. SETTING: Sweden. PARTICIPANTS: Older people aged 75 to 89 who, filled at least one drug prescription between August and October 2005 and, consequently, were listed in the Swedish Prescribed Drug Register (SPDR) (N=626,258). Data were obtained from the SPDR, the inpatient register, and the education register. MEASUREMENTS: The main outcome measures were polypharmacy (concurrent use of ≥5 drugs), excessive polypharmacy (concurrent use of ≥10 drugs), and potential IDU. Four quality indicators developed by the Swedish National Board of Health and Welfare were used for the assessment of potential IDU: concurrent use of three or more psychotropic drugs, prescription of long-acting benzodiazepines, prescription of anticholinergics, and at least one clinically relevant potential drug–drug interaction (DDI). Comorbidity was measured using the Charlson Comorbidity Index. RESULTS: Subjects with low education had a higher probability of polypharmacy (odds ratio (OR)=1.11, 95% confidence interval (CI)=1.10–1.12), excessive polypharmacy (OR=1.15, 95% CI=1.13–1.17), and potential IDU (OR=1.09, 95% CI=1.07–1.17), after adjustment for age, sex, comorbidity, and type of residential area (urban or rural). Decreasing educational attainment was associated with a higher probability of using three or more psychotropic drugs and potential DDIs, whereas the opposite association was observed for anticholinergic drugs. Long-acting benzodiazepines showed no association. Elderly women with low education were slightly more likely to have polypharmacy, excessive polypharmacy, and potential IDU than men with low education. Overall, the ORs were modest and statistically significant because of the large sample size. CONCLUSION: Low educational attainment was associated with a greater likelihood of poypharmacy, excessive polypharmacy, and potential IDU in elderly Swedish persons, even after controlling for age, sex, place of residence, and comorbidity. Women with low education had slightly higher likelihood of receiving polypharmacy and potential IDU than men with low education. The recently established SPDR may be useful for continuous monitoring and for designing interventions to improve drug quality in low-educated elderly people. [ABSTRACT FROM AUTHOR]

To examine the association between educational level and the use of newly marketed drugs (NMD) among elderly persons. We conducted a register-based, retrospective, cross-sectional study of 626,258 people aged 75–89 years who filled at least one drug prescription from August to October 2005 and who, consequently, were registered in the Swedish Prescribed Drug Register (SPDR). Data from the SPDR were record-linked to the Swedish National Inpatient Register and the Education Register. Newly marketed drugs were defined as new chemical entities that had been approved in Sweden between 2000 and 2004. Overall, NMD were prescribed to 7.3% of the study population. The use of NMD increased with increasing educational level (6.9% for the lowest educated elderly and 8.1% for the highest educated elderly), and education was associated with NMD [odds ratio (OR) 0.82; 95% confidence interval (CI)] 0.80–0.88 for <9 compared with ≥13 years of education) after adjustment for age, sex, type of residential area and number of dispensed drugs. Decreasing educational level was associated with a lower probability of using most of the NMD, especially oseltamivir (adjusted OR 0.16; 95% CI 0.12–0.22 for <9 years of education compared with ≥13 years of education) and ezetimibe. This study suggests that education-related inequalities in NMD use may exist even in a healthcare system that claims to ensure a high degree of equity. Future research is required to explain why educational level influences the selection of new drugs and whether it has any impact on health outcomes. [ABSTRACT FROM AUTHOR]

To investigate whether cardiovascular drug classes and specific beta-blockers are associated with antidepressant drug use in a large study population of older people. We analyzed data from the Swedish Prescribed Drug Register from October-December 2005 for people aged 75 years and older ( n = 732,230). Logistic regression analysis was used to study the association between the cardiovascular drugs and antidepressants, after adjustment for age, sex, and number of other dispensed drugs. All the cardiovascular drug classes were negatively or not associated with use of any antidepressant, non-selective monoamine reuptake inhibitors, and SSRIs, after adjustment for age, sex, and number of other dispensed drugs. However, propranolol was associated with an increased use of any antidepressant, non-selective monoamine reuptake inhibitors, and SSRIs, after adjustment for age, sex, and number of other dispensed drugs. Atenolol was positively associated with non-selective monoamine reuptake inhibitors, although to a lesser extent than propranolol. None of the cardiovascular drug classes were associated with increased antidepressant drug use, after adjustment for age, sex, and use of other drugs. However, when focusing specifically on beta-blockers, our results indicate that propranolol may be the beta-blocker most closely associated with use of antidepressants in the elderly. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: NSAIDs and cyclo-oxgenase (COX)-2-selective inhibitors have been associated with gastrointestinal (GI) complications among the elderly. It is recommended that gastroprotective drugs (i.e. misoprostol, proton pump inhibitors or high doses of histamine H2 receptor antagonists) be taken concomitantly to prevent NSAID-induced GI complications among older people. However, there are concerns that the rate of concomitant use of gastroprotective drugs in elderly NSAID users is too low. This study aimed to investigate the extent to which elderly users of NSAIDs/COX-2-selective inhibitors are concurrently taking gastroprotective drugs, and to determine the factors associated with concomitant use of gastroprotective drugs and NSAIDs/COX-2-selective inhibitors in a nationwide population of older people. METHODS: We analysed data on age, sex and dispensed drugs for people ≥75 years of age registered in the Swedish Prescribed Drug Register from October to December 2005 (n = 732 230) and located 41 626 NSAID/COX-2-selective inhibitor users. Logistic regression analysis was used for analysing the association between the use of different NSAIDs/COX-2-selective inhibitors and gastroprotective drugs, and between individual characteristics and use of gastroprotective drugs. RESULTS: Gastroprotective drugs were used by 22% of NSAID/COX-2-selective inhibitor users. Celecoxib, ketoprofen, meloxicam and etoricoxib were most commonly used concomitantly with gastroprotective drugs. Meloxicam and celecoxib were most strongly associated with gastroprotective drugs, after adjustment for age, sex and number of other drugs. Furthermore, NSAID/COX-2-selective inhibitor + oral corticosteroid users, NSAID/COX-2-selective inhibitor + selective serotonin reuptake inhibitor users and users of two or more NSAIDs/COX-2-selective inhibitors were more likely to concomitantly use gastroprotective drugs compared with NSAID/COX-2-selective inhibitor only users, after adjustment for age, sex and number of other drugs. However, users of NSAIDs/COX-2-selective inhibitors + anticoagulants (both warfarin and low-dose aspirin [acetylsalicylic acid]) did not show an increased likelihood of concomitant use of gastroprotective drugs, after adjustment for age, sex and number of other drugs. CONCLUSION: Our results indicate that gastroprotective drugs are not prescribed to elderly NSAID users according to guidelines. Furthermore, COX-2-selective inhibitors were used with gastroprotective drugs more often than were traditional NSAIDs. Greater awareness of factors contributing to NSAID/COX-2-selective inhibitor-induced GI complications is warranted, particularly with respect to advanced age and concurrent use of anticoagulants. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although cholinesterase inhibitors are used for the treatment of Alzheimer’s disease, the clinical benefits of these drugs are being questioned. Anticholinergic drugs have the opposite pharmacological action to cholinesterase inhibitors, and may antagonize the effects of cholinesterase inhibitors. Therefore, this drug combination should be avoided. Nevertheless, high rates of concurrent use of anticholinergic drugs and cholinesterase inhibitors have been reported in the US. To the authors’ knowledge, use of this inappropriate drug combination has not been studied outside North America. OBJECTIVE: To investigate (i) whether anticholinergic drug use is more common among users than non-users of cholinesterase inhibitors, and (ii) which factors are associated with use of anticholinergic drugs among users of cholinesterase inhibitors. METHODS: We analysed data on age, sex, type of residential area (urban/rural) and drugs dispensed for patients aged ≥75 years registered in the Swedish Prescribed Drug Register from October to December 2005 (n = 731 105). The prevalence of use of anticholinergic drugs in users of cholinesterase inhibitors was compared with that in non-users of cholinesterase inhibitors and logistic regression was used to study the association between use of cholinesterase inhibitors and anticholinergic drugs. Logistic regression was also used to analyse whether age, sex, type of residential area or number of dispensed drugs was associated with use of anticholinergic drugs among users of cholinesterase inhibitors (n = 18 326). RESULTS: Anticholinergic drug use was more common among cholinesterase inhibitor users than non-users, particularly in men, of whom 9% who were taking cholinesterase inhibitors were dispensed anticholinergic drugs compared with 5% who were not taking cholinesterase inhibitors. Use of cholinesterase inhibitors was associated with use of anticholinergic drugs in men (odds ratio 1.23; 95% CI 1.13, 1.35), after adjustment for age, type of residential area and number of dispensed drugs. Male sex and use of many drugs were independently associated with concurrent use of anticholinergic drugs and cholinesterase inhibitors. CONCLUSION: Anticholinergic drug use is more common among cholinesterase inhibitor users than non-users, even though anticholinergic drugs may antagonize the effect of cholinesterase inhibitors. Hence, if the true clinical effects of cholinesterase inhibitors are to be accurately assessed, they need to be studied in the absence of anticholinergic drugs. [ABSTRACT FROM AUTHOR]

Objective. To investigate whether the use of multi-dose drug dispensing is associated with potentially inappropriate drug use (IDU). Design. Cross-sectional nationwide register-based study. Setting. Sweden. Subjects. People aged ≥75 years registered in the Swedish Prescribed Drug Register during October-December 2005. Main outcome measures. Potentially IDU, i.e. anticholinergic drugs, long-acting benzodiazepines, concurrent use of three or more psychotropic drugs, and combinations of drugs that may lead to potentially serious drug-drug interactions (DDIs). Results. After adjustment for age and number of dispensed drugs, any IDU, anticholinergic drugs, and three or more psychotropic drugs were associated with multi-dose drug dispensing, whereas the opposite relationship prevailed for long-acting benzodiazepines among women and potentially serious DDIs in both men and women. Among the subjects aged 75-79 years, multi-dose drug dispensing was even more strongly associated with any IDU, anticholinergic drugs, three or more psychotropic drugs in both men and women, and long-acting benzodiazepines among men. Conclusion. Our results indicate that multi-dose users may be more exposed to potential IDU. However, multi-dose users seem to have a lower probability of potentially serious DDIs. Future research on multi-dose drug dispensing is necessary to ensure a high quality of drug therapy within this system. [ABSTRACT FROM AUTHOR]

Abstract: Background: Polypharmacy is an important patient safety concern and has been associated with increased adverse drug reactions, hospitalization, and mortality in the elderly. However, few studies have analyzed the association between socioeconomic position (SEP) and the extent of drug use in older people. Objectives: The aims of this study were to investigate the prevalence of polypharmacy and the association between polypharmacy and SEP, as measured by education, occupation, and income. Methods: For this cross-sectional study, data from a nationally representative sample (Swedish Panel Study of Living Conditions of the Oldest Old [SWEOLD] 2002) aged ≥77 years were analyzed (n = 621). Information on drug use was based on personal interviews, and polypharmacy was defined as concurrent use of ≥5 drugs. Other measurements included were age, sex, education, occupation, income, comorbidity, marital status, and living situation. The association between polypharmacy and SEP was assessed by logistic regression. Results: The mean number of drugs used in the sample was 4.4; in less educated patients, 4.6; more educated, 4.0. Polypharmacy was observed in 42.2% of the elderly. Overall, antithrombotic agents (42.5%), P-blocking agents (28.3%), and high-ceiling diuretics (28.0%) were the most prevalent drugs. Low education was associated with polypharmacy (odd ratio [OR], 1.46; 95% CI, 1.02‐2.07), after controlling for age and sex. However, the association between low education level and polypharmacy was not significant after adjustment for age, sex, comorbidity, marital status, and living situation (OR, 1.39; 95% CI, 0.95‐2.04). Moreover, we did not observe any association between occupation or income and polypharmacy. Conclusions: The results from this study suggest that >40% of people aged ≥77 years in Sweden are exposed to polypharmacy, defined as the use of ≥5 drugs. There was a higher prevalence of polypharmacy among elderly with low education. However, after controlling for comorbidity, martial status, and living situation, polypharmacy was not related to low education. Further studies in larger populations are needed to elucidate the association between SEP and drug use. [Copyright &y& Elsevier]

Background/Aims: Low education has been shown to be a risk factor for dementia. However, little is known about the association between educational level and dementia drugs. Methods: We conducted a register-based study in Sweden of 645,973 people aged 75–89 years. Data on age, sex, type of residential area (urban/rural), dispensed drugs and education were analyzed from people aged 75–89 years registered in the Swedish Prescribed Drug Register during July to October 2005. The 3 main outcome measures were dispensed dementia drugs, cholinesterase inhibitors (donepezil, rivastigmine and galantamine) and memantine. Results: Dementia drugs were used by 3% of the study population, cholinesterase inhibitors by almost 3% and memantine by 0.4%. High education was associated with dementia drugs (OR: 1.26; 95% CI: 1.19–1.34 for ≥15 years of education compared with ≤9 years), cholinesterase inhibitors (OR: 1.25; 95% CI: 1.17–1.33 for ≥15 years of education compared with ≤9 years) and, especially, memantine (OR: 1.46; 95% CI: 1.26–1.68 for ≥15 years of education compared with ≤9 years), after adjustment for age, sex, type of residential area and number of dispensed drugs. Conclusion: The results indicate that there may be inequalities in the use of dementia drugs among elderly Swedes. Future research is required to explain why educational level has the opposite relationship to dementia drugs than to dementia diagnosis. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Drug-drug interactions (DDIs) are of great concern, as they are known to be related to adverse drug reactions and hospitalisations. In addition, many DDIs are regarded as predictable and avoidable; therefore, they may be considered as targets for education and interventions.Objective: To analyse the relationship between number of dispensed drugs and the probability of potential DDIs among the elderly by using the new Swedish Prescribed Drug Register.Methods: We analysed data on age, sex and dispensed drugs for people aged > or = 75 years who were registered in the Swedish Prescribed Drug Register from October to December 2005, and constructed a list of current prescriptions for every individual on the arbitrarily chosen date of 31 December 2005. Thereafter, we included those who had at least two dispensed drugs to capture the elderly population at risk of being exposed to DDIs (n = 630 743). The main outcome measures were potentially clinically relevant DDIs (type C), which may require dose adjustment, and potentially serious DDIs (type D), which should be avoided.Results: The prevalence of type C potential DDIs was 26% and of type D potential DDIs 5% in the study population. There was a strong association between number of dispensed drugs and the probability of type C potential DDIs and an even stronger association for type D potential DDIs, after adjustment for age and sex. In addition, the probability of type D potential DDIs decreased with increasing age, and women had a lower probability of type D potential DDIs than men.Conclusion: There seems to be a strong relationship between number of dispensed drugs and potential DDIs, especially for potentially serious DDIs, which has implications for the importance of trying to minimise the number of drugs prescribed in the elderly. Our findings that the probability of potentially serious DDIs decreases with increasing age among the elderly and that elderly women have a lower probability of potentially serious DDIs than elderly men need to be verified and investigated by further research. [ABSTRACT FROM AUTHOR]

Background: Drug-drug interactions (DDIs) are of great concern, as they are known to be related to adverse drug reactions and hospitalisations. In addition, many DDIs are regarded as predictable and avoidable; therefore, they may be considered as targets for education and interventions. Objective: To analyse the relationship between number of dispensed drugs and the probability of potential DDIs among the elderly by using the new Swedish Prescribed Drug Register. Methods: We analysed data on age, sex and dispensed drugs for people aged =75 years who were registered in the Swedish Prescribed Drug Register from October to December 2005, and constructed a list of current prescriptions for every individual on the arbitrarily chosen date of 31 December 2005. Thereafter, we included those who had at least two dispensed drugs to capture the elderly population at risk of being exposed to DDIs (n = 630 743). The main outcome measures were potentially clinically relevant DDIs (type C), which may require dose adjustment, and potentially serious DDIs (type D), which should be avoided. Results: The prevalence of type C potential DDIs was 26% and of type D potential DDIs 5% in the study population. There was a strong association between number of dispensed drugs and the probability of type C potential DDIs and an even stronger association for type D potential DDIs, after adjustment for age and sex. In addition, the probability of type D potential DDIs decreased with increasing age, and women had a lower probability of type D potential DDIs than men. Conclusion: There seems to be a strong relationship between number of dispensed drugs and potential DDIs, especially for potentially serious DDIs, which has implications for the importance of trying to minimise the number of drugs prescribed in the elderly. Our findings that the probability of potentially serious DDIs decreases with increasing age among the elderly and that elderly women have a lower probability of potentially serious DDIs than elderly men need to be verified and investigated by further research. [ABSTRACT FROM AUTHOR]

Abstract: The concept of social capital has gained wide interest in public health research in recent years. However, we suggest a concept that was introduced and developed by Fukuyama, named “miniaturization of community”, as an alternative to that of social capital. The concept of miniaturization of community emphasizes that a high level of social participation can be accompanied by a low level of trust, both at the individual and at the community level, which may in turn result in social disorder and lack of social cohesion. When society becomes more disordered, people may tend to feel more insecure and anxious. Use of anxiolytic–hypnotic drugs (AHDs) could under such circumstances be a coping strategy. In this study, we first wanted to investigate whether the contextual component of the miniaturization of community concept (i.e. area high social participation and low trust) is associated with individual AHD use, over and above individual characteristics. Secondly, we aimed to study whether people living in the same municipality share a similar probability of AHD use, after adjusting for individual characteristics, and if so, how large this contextual phenomenon is. We used data on 20,319 women and 17,850 men aged 18–79 years from 58 municipalities in six regions in central Sweden, who participated in the Life & Health year 2000 postal survey. We applied multilevel logistic regression analysis with individuals at the first level and areas at the second level. Our results suggest that living in an area with a high level of miniaturization of community seems to be associated with individual AHD use, beyond people''s individual characteristics including their own level of social participation and trust. The concept of miniaturization of community may be an extension of the classic concept of social capital and may increase our understanding of contextual effects on health. [Copyright &y& Elsevier]

Background: Non-concordance with medication remains a major public health problem that imposes a considerable financial burden on the health care system, and there is still a need for studies on correlates of non-concordance. Our first aim is to analyse whether any of the individual characteristics age, educational level, financial strain, self-rated health, social participation, and trust in the health care system are associated with primary non-concordance with medication. Our second aim is to investigate whether people living in the same area have similar probability of primary non-concordance with medication, that relates to area social participation. Methods: We analysed cross sectional data from 9 070 women and 6 795 men aged 18 to 79 years, living in 78 areas in central Sweden, who participated in the Life & Health year 2000 survey, with multilevel logistic regression (individuals at the first level and areas at the second level). Results: Younger age, financial strain, low self-rated health, and low trust in the health care system were associated with primary non-concordance with medication. However, area social participation was not related to primary non-concordance, and the variation in primary non-concordance between the areas was small. Conclusion: Our results indicate that people in central Sweden with younger age, financial difficulties, low self-rated health, and low trust in the health care system may have a higher probability of primary non-concordance with medication. However, the area of residence - as defined by administrative boundaries - seems to play a minor role for primary non-concordance. [ABSTRACT FROM AUTHOR]

Aims: The increasing number of people on disability pension in Sweden is of concern for Swedish policy-makers, and there is a need for a better understanding of the mechanisms behind disability pension. We investigated (i) whether women living in the same neighborhood have a similar propensity for disability pension that relates to neighborhood social participation, and (ii) whether there is an association between anxiolytic-hypnotic drug (AHD) use and disability pension in women that is modified by the neighborhood context. Methods: We used multilevel logistic regression with 12,156 women aged 45 to 64 (first level) residing in 95 neighborhoods (second level) in the city of Malmö (250,000 inhabitants), Sweden, who participated in the Malmö Diet and Cancer Study (1991–96). Results: Both AHD use (OR = 2.09, 95% CI 1.65, 2.65) and neighborhood rate of low social participation (OR = 11.85, 95% CI 5.09, 27.58) were associated with higher propensity for disability pension. The interval odds ratio indicated that the influence of neighborhood social participation was large compared with the unexplained variance between the neighborhoods. The association between AHD use and disability pension was not modified by the neighborhood context. The median odds ratio was 1.44 after adjusting for individual characteristics and 1.27 after the additional adjusting for neighborhood social participation. Conclusions: Women living in the same neighborhood appear to have a similar propensity for disability pension, beyond individual characteristics, and this contextual effect seems largely explained by neighborhood social participation. In addition, AHD use might increase the propensity for disability pension in women. [ABSTRACT FROM AUTHOR]

Background: Low adherence is a key factor in explaining impaired effectiveness and efficiency in the pharmacological treatment of hypertension. However, little is known about which factors determine low adherence in actual practice. The purpose of this study is to examine whether low social participation is associated with low adherence with antihypertensive medication, and if this association is modified by the municipality of residence. Methods: 1288 users of antihypertensive medication were identified from The Health Survey in Scania 2000, Sweden. The outcome was low adherence with antihypertensives during the last two weeks. Multilevel logistic regression with participants at the first level and municipalities at the second level was used for analyses of the data. Results: Low social participation was associated with low adherence with antihypertensives during the last two weeks (OR = 2.05, 95% CI: 1.05-3.99), independently of low educational level. However, after additional adjustment for poor self-rated health and poor psychological health, the association between low social participation and low adherence with antihypertensives during the last two weeks remained but was not conclusive (OR = 1.80, 95% CI: 0.90-3.61). Furthermore, the association between low social participation and low adherence with antihypertensives during the last two weeks varied among municipalities in Scania (i.e., cross-level interaction). Conclusion: Low social participation seems to be associated with low adherence with antihypertensives during the last two weeks, and this association may be modified by the municipality of residence. Future studies aimed at investigating health-related behaviours in general and low adherence with medication in particular might benefit if they consider area of residence. [ABSTRACT FROM AUTHOR]

Background: Medication use around widowhood has been poorly described for most medication classes. Medication use patterns can reflect health consequences of spousal loss, as previously shown for psychotropic drugs. Methods: We used data from nationwide health registers (2008–2020) to describe the patterns of use of dispensed medications in all widowed Swedes aged ≥65 years followed between 2 years before and 2 years after spousal death. All prescription drugs used by at least 5% of the cohort were considered according to their therapeutic subgroups (Anatomical Therapeutic Chemical [ATC] classification system 2nd level). We used group‐based trajectory models to cluster widowed individuals into up to 4 distinct longitudinal patterns of monthly medication use. We ranked the therapeutic subgroups with similar patterns according to their plausibility to reflect potential health effects of spousal loss, compared to those of psycholeptics (mainly anxiolytics, hypnotics) and psychoanaleptics (mainly antidepressants) as the references. Results: From 212,111 widowed adults included (68% female and 70% aged ≥75 years), we observed a significant increasing trend in medication use, especially after spousal death, for 21 out of the 39 different therapeutic subgroups that were used by at least 5% (most represented pharmacological groups: cardiovascular system, nervous system, and alimentary tract and metabolism). This increasing trend often concerned only a small proportion of individuals, with varying magnitude and speed of change in medication use across therapeutic subgroups. The patterns of use of antiepileptics, laxatives, skin emollients/protectives, analgesics, and drugs for anemia, constipation, or peptic ulcers, were the closest to those of references, displaying the largest changes in use, and were therefore ranked as the most likely to reflect health effects of spousal loss. Conclusion: Our results confirmed the increase in psychotropic medications' use in widowed older adults and identified several potential physical health effects of spousal loss that warrant further research. [ABSTRACT FROM AUTHOR]

Aim: To describe long-term care (LTC) use in Finland and Sweden in 2020, by reporting residential entry and exit patterns including hospital admissions and mortality, compared with the 2018–2019 period and community-living individuals. Methods: From national registers in Finland and Sweden, all individuals 70+ were included. Using the Finnish and Swedish study populations in January 2018 as the standard population, we reported changes in sex- and age-standardized monthly rates of entry into and exit from LTC facilities, mortality and hospital admission among LTC residents and community-living individuals in 2020. Results: Around 850,000 Finns and 1.4 million Swedes 70+ were included. LTC use decreased in both countries from 2018 to 2020. In the first wave (March/April 2020), Finland experienced a decrease in LTC entry rates and an increase in LTC exit rates, both more marked than Sweden. This was largely due to short-term movements. Mortality rates peaked in April and December 2020 for LTC residents in Finland, while mortality peaked for both community-living individuals and LTC residents in Sweden. A decrease in hospital admissions from LTC facilities occurred in April 2020 and was less marked in Finland versus Sweden. Conclusions: During the first wave of the pandemic mortality was consistently higher in Sweden. We also found a larger decrease in LTC use and, among LTC residents, a smaller decrease in hospital admissions in Finland than in Sweden. This study calls for assessing the health consequences of the differences observed between these two Scandinavian countries as part of the lessons from the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

The authors reflect on the report of H-F. Kwint and colleagues regarding the community-dwelling recipients of multidose drug dispensing (MDD) in the Netherlands, which have better medication support but poor quality medication knowledge. They state that the recipients of MDD were less likely than those who receives manual dispensed medications. They add that most study on MDD and not suitable medication use has been cross-sectional.

Background: Non‐steroidal anti‐inflammatory drugs (NSAIDs) should be used with caution in adults aged 65 years and older. Their gastrointestinal adverse event risk might be further reinforced when using concomitant cholinesterase inhibitors (ChEIs). We aimed to investigate the association between NSAIDs and ChEI use and the risk of peptic ulcers in adults aged 65 years and older. Methods: Register‐based self‐controlled case series study including adults ≥65 years with a new prescription of ChEIs and NSAIDs, diagnosed with incident peptic ulcer in Sweden, 2007–2020. We identified persons from the Total Population Register individually linked to several nationwide registers. We estimated the incidence rate ratio (IRR) of peptic ulcer with a conditional Poisson regression model for four mutually exclusive risk periods: use of ChEIs, NSAIDs, and the combination of ChEIs and NSAIDs, compared with the non‐treatment in the same individual. Risk periods were identified based on the prescribed daily dose, extracted via a text‐parsing algorithm, and a 30‐day grace period. Results: Of 70,060 individuals initiating both ChEIs and NSAIDs, we identified 1500 persons with peptic ulcer (median age at peptic ulcer 80 years), of whom 58% were females. Compared with the non‐treatment periods, the risk of peptic ulcer substantially increased for the combination of ChEIs and NSAIDs (IRR: 9.0, [6.8–11.8]), more than for NSAIDs alone (5.2, [4.4–6.0]). No increased risks were found for the use of ChEIs alone (1.0, [0.9–1.2]). Discussion: We found that the risk of peptic ulcer associated with the concomitant use of NSAIDs and ChEIs was over and beyond the risk associated with NSAIDs alone. Our results underscore the importance of carefully considering the risk of peptic ulcers when co‐prescribing NSAIDs and ChEIs to adults aged 65 years and older. [ABSTRACT FROM AUTHOR]

Background Some studies have linked late-life overweight to a reduced mortality risk compared to normal body mass index (BMI). However, the impact of late-life overweight and its combination with mid-life BMI status on healthy survival remains unclear. We aimed to investigate whether and to what extent mid- and/or late-life overweight are associated with chronic disease-free survival. Methods Within the Swedish Twin Registry, 11 597 chronic disease-free twins aged 60−79 years at baseline were followed up for 18 years. BMI (kg/m2) was recorded at baseline and 25−35 years before baseline (ie, midlife) and divided as underweight (<20), normal (≥20−25), overweight (≥25−30), and obese (≥30). Incident chronic diseases (cardiovascular diseases, type 2 diabetes, and cancer) and deaths were ascertained via registries. Chronic disease-free survival was defined as years lived until the occurrence of any chronic diseases or death. Data were analyzed using multistate survival analysis. Results Of all participants, 5 640 (48.6%) were overweight/obese at baseline. During the follow-up, 8 772 (75.6%) participants developed at least 1 chronic disease or died. Compared to normal BMI, late-life overweight and obesity were associated with 1.1 (95% CI, 0.3, 2.0) and 2.6 (1.6, 3.5) years shorter chronic disease-free survival. Compared to normal BMI through mid- to late life, consistent overweight/obesity and overweight/obesity only in mid-life led to 2.2 (1.0, 3.4) and 2.6 (0.7, 4.4) years shorter disease-free survival, respectively. Conclusions Late-life overweight and obesity may shorten disease-free survival. Further research is needed to determine whether preventing overweight/obesity from mid- to late life might favor longer and healthier survival. [ABSTRACT FROM AUTHOR]

Background: Long-term care improves independence and quality of life of persons with dementia (PWD). The influence of socioeconomic status on access to long-term care was understudied. Objective: To explore the socioeconomic disparity in long-term care for PWD. Methods: This registry-based study included 14,786 PWD, registered in the Swedish registry for cognitive and dementia disorders (2014–2016). Education and income, two traditional socioeconomic indicators, were the main exposure. Outcomes were any kind of long-term care, specific types of long-term care (home care, institutional care), and the monthly average hours of home care. The association between outcomes and socioeconomic status was examined with zero-inflated negative binomial regression and binary logistic regression. Results: PWD with compulsory education had lower likelihood of receiving any kind of long-term care (OR 0.80, 95% CI 0.68–0.93), or home care (OR 0.83, 95% CI 0.70–0.97), compared to individuals with university degrees. Their monthly average hours of home care were 0.70 times (95% CI 0.59–0.82) lower than those of persons with university degrees. There was no significant association between education and the receipt of institutional care. Stratifying on persons with Alzheimer's disease showed significant association between lower education and any kind of long-term care, and between income and the hours of home care. Conclusions: Socioeconomic inequalities in long-term care existed in this study population. Lower-educated PWD were less likely to acquire general long-term care, home care and had lower hours of home care, compared to their higher-educated counterparts. Income was not significantly associated with the receipt of long-term care. [ABSTRACT FROM AUTHOR]

The author reflects on the study of Huizer-Pajkos and colleagues on the efficacy of a mouse model in polypharmacy. The author argues on the population of the study as it was conducted to a control population of male mice by feeding them with doses of commonly used medicines by older people. The author cites the importance of the study among older people.

We aim to analyze the risk of death from specific external causes, including falls, complications of medical and surgical care, unintentional injuries, and suicide, in dementia patients. Swedish nationwide cohort study integrating 6 registers from May 1, 2007, through December 31, 2018, including the Swedish Registry for Cognitive/Dementia Disorders (SveDem). Population-based study. Patients diagnosed with dementia from 2007 to 2018 and up to 4 controls matched on year of birth (±3 years), sex, and region of residence. The exposures of this study were diagnosis of dementia and dementia subtypes. Number of deaths and causes of mortality were obtained from death certificates compiled into the Cause of Death Register. Hazard ratios (HRs) and 95% CIs were estimated using Cox and flexible models, adjusted for sociodemographics, medical and psychiatric disorders. The study population included 235,085 patients with dementia [96,760 men (41.2%); mean age 81.5 (SD 8.5) years] and 771,019 control participants [341,994 men (44.4%); mean age 79.9 (SD 8.6) years], over 3,721,687 person-years. Compared with control participants, patients with dementia presented increased risk for unintentional injuries (HR 3.30, 95% CI 3.19-3.40) and falls (HR 2.67, 95% CI 2.54-2.80) during old age (≥75 y), and suicide (HR 1.56, 95% CI 1.02-2.39) in middle age (<65 y). Suicide risk was 5.04 times higher (HR 6.04, 95% CI 4.22-8.66) in patients with both dementia and 2 or more psychiatric disorders relative to controls (incidence rate per person-years, 1.6 vs 0.3). For dementia subtypes, frontotemporal dementia had the highest risks of unintentional injuries (HR 4.28, 95% CI 2.80-6.52) and falls (HR 3.83, 95% CI 1.98-7.41), whereas subjects with mixed dementia were less likely to die from suicide (HR 0.11, 95% CI 0.03-0.46) and complications of medical and surgical care (HR 0.53, 95% CI 0.40-0.70) compared to controls. Suicide risk screening and psychiatric disorders management in early-onset dementia and early interventions for unintentional injuries and falls prevention in older dementia patients should be provided. [ABSTRACT FROM AUTHOR]

Background: The aging of our societies leads to a higher prevalence of multimorbidity and therefore polypharmacy, which often results in inappropriate drug treatment. To address this issue, numerous listing approaches, such as the Fit fOR The Aged (FORTA) list have been developed. FORTA's positive impact on the quality of medications and relevant clinical outcomes has been shown. Based on new emerging evidence and experiences with the existing FORTA lists, we aimed to update the FORTA lists in several European countries/regions. Methods: Two-step Delphi consensus procedures were conducted in Poland, UK/Ireland, Italy, Spain, the Nordic countries, The Netherlands and France. The existing European FORTA lists served as survey proposals. Results: Thirty-two experts agreed to take part in this study (return rate: 96.9%). The country/region-specific overall consensus for all items and participants after the first round was > 90%. FORTA lists from six participating countries, plus the FORTA list for the German-speaking countries, were collated into the new EURO-FORTA List, which now contains 267 items aligned to 27 indications. Three items were added to the EURO-FORTA List, and no drugs were deleted. Eight FORTA items were relabeled, and 96.9% of the labels remained unchanged. Conclusion: In this study, seven new country/region specific FORTA lists, as well as a new overarching EURO-FORTA List, were developed. An overall increase in the mean consensus coefficient and increases for all disease-specific mean consensus coefficients show a wider consensus among participants. The new lists have the potential to improve drug therapy in older people internationally. [ABSTRACT FROM AUTHOR]

Medication management is becoming increasingly challenging for older people, and there is limited evidence to guide medication prescribing and administration for people with multimorbidity, frailty, or at the end of life. Currently, there is a lack of clear research priorities in the field of geriatric pharmacotherapy. To address this issue, international experts from 5 research groups in geriatric pharmacotherapy and pharmacoepidemiology research were invited to attend the inaugural Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network workshop. A modified nominal group technique was used to explore and consolidate the priorities for conducting research in this field. Eight research priorities were elucidated: quality of medication use; vulnerable patient groups; polypharmacy and multimorbidity; person-centered practice and research; deprescribing; methodological development; variability in medication use; and national and international comparative research. The research priorities are discussed in detail in this article with examples of current gaps and future actions presented. These priorities highlight areas for future research in geriatric pharmacotherapy to improve medication outcomes in older people. [ABSTRACT FROM AUTHOR]

Background Trends in the use of antithrombotic drugs in elderly patients with atrial fibrillation (AF) are largely unknown. We estimated the prevalence of AF in an older population, and examined whether use of anticoagulant and antiplatelet drugs in older AF patients has changed over time. Methods Data from the population-based Swedish National study on Aging and Care in Kungsholmen ( n = 3363, age ≥ 60 years, 64.9% women) were used (2001–2004 and 2007–2010). AF cases were identified through 12-lead electrocardiogram, physician examinations, and patient register records (ICD-10 code I48). We used the CHADS 2 and CHA 2 DS 2 -VASc scores to estimate stroke risk, and an incomplete HAS-BLED score to estimate bleeding risk. Results At baseline (2001–2004), 328 persons (9.8%) were ascertained to have AF. The prevalence of AF increased significantly with age from 2.8% in people aged 60–66 years to 21.2% in those ≥ 90 years, and was more common in men than in women (11.2% vs. 9.0%). Among AF patients with CHADS 2 score ≥ 2 at baseline, 25% were taking anticoagulant drugs and 54% were taking antiplatelet drugs. High bleeding risk was significantly associated with not using anticoagulant drugs in AF patients (multi-adjusted OR = 2.50, p = 0.015). Between 2001–2004 and 2007–2010, use of anticoagulant drugs increased significantly, especially in AF patients with CHA 2 DS 2 -VASc score ≥ 2 (23% vs. 33%, p = 0.008) and in those with HAS-BLED score < 3 (32% vs. 53%, p = 0.004). Conclusion AF is common among old people. The use of anticoagulant drugs increased over time in AF patients, yet still two-thirds of those with high stroke risk remained untreated. [ABSTRACT FROM AUTHOR]