[Show abstract][Hide abstract] ABSTRACT: Background
Behavioural and psychological symptoms of dementia are frequently treated with antipsychotics.AimsTo determine the incidence of antipsychotic use in relation to diagnosis of Alzheimer's disease.Method
Cohort of all community-dwellers in Finland diagnosed with Alzheimer's disease in 2005 and matched controls. All antipsychotics dispensed between 1995 and 2009 were extracted from the Finnish National Prescription Register.ResultsAltogether 1996/6087 (32.8%) persons with Alzheimer's disease initiated antipsychotic use. The incidence of antipsychotic use was fivefold among persons with Alzheimer's disease compared with controls, started to increase 2-3 years before diagnosis and was highest during the first 6 months after diagnosis.ConclusionsA distinct increase in antipsychotic initiations occurs in the same time window as Alzheimer's disease diagnosis.
The British journal of psychiatry: the journal of mental science 10/2015; DOI:10.1192/bjp.bp.114.162834 · 7.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Cardiovascular diseases are leading causes of death and patients with dementia are often affected by them.
Investigate associations of cardiovascular diseases with different dementia disorders and determine their impact on mortality.
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.
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).
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.
[Show abstract][Hide abstract] ABSTRACT: Background:
The influence of mixed dietary patterns on cognitive changes is unknown.
A total of 2223 dementia-free participants aged ≥60 were followed up for 6 years to examine the impact of dietary patterns on cognitive decline. Mini-mental state examination (MMSE) was administrated. Diet was assessed by a food frequency questionnaire. By factor analysis, Western and prudent dietary patterns emerged. Mixed-effect models for longitudinal data with repeated measurements were used.
Compared with the lowest adherence to each pattern, the highest adherence to prudent pattern was related to less MMSE decline (β = 0.106, P = .011), whereas the highest adherence to Western pattern was associated with more MMSE decline (β = -0.156, P < .001). The decline associated with Western diet was attenuated when accompanied by high adherence to prudent pattern.
High adherence to prudent diet may diminish the adverse effects of high adherence to Western diet on cognitive decline.
Alzheimer's & dementia: the journal of the Alzheimer's Association 09/2015; DOI:10.1016/j.jalz.2015.08.002 · 12.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Inappropriate drug use (IDU) is an important risk factor for adverse outcomes in older persons. We aimed to investigate IDU and the risk of hospitalizations and mortality in older persons and in persons with dementia and to estimate the costs of IDU-related hospitalizations.
We analyzed 4108 individuals aged ≥60 years from the Swedish National Study on Aging and Care (SNAC) data from Kungsholmen and Nordanstig (2001-2004). IDU was assessed by indicators developed by the Swedish National Board of Health and Welfare. Hospitalizations and mortality data were collected from Swedish registers. Regression models were used to investigate associations between IDU, hospitalizations, and mortality in the whole population and in the subpopulation of persons with dementia (n = 319), after adjustment for sociodemographics, physical functioning, and co-morbidity. Costs for hospitalizations were derived from the Nord-Diagnose Related Group cost database.
IDU was associated with a higher risk of hospitalization [adjusted odds ratio (OR) = 1.46; 95 % confidence interval (CI) 1.18-1.81] and mortality [adjusted hazard ratio (HR) = 1.15; 95 % CI 1.01-1.31] within 1 year in the whole study population and with hospitalization (adjusted OR = 1.88; 95 % CI 1.03-3.43) in the subpopulation of persons with dementia, after adjustment for confounding factors. There was also a tendency for higher costs for hospitalizations with IDU than without IDU, although this was not statistically significant.
Our findings suggest that IDU is associated with an increased risk of hospitalization in older persons and in persons with dementia. IDU is also associated with mortality among older persons. These findings highlight the need for cautious prescribing of long-acting benzodiazepines, anticholinergic drugs, concurrent use of three or more psychotropic drugs and drug combinations that may lead to serious drug-drug interactions to older patients. Further studies are needed to investigate the association between IDU and costs for hospitalizations.
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
European Journal of Clinical Pharmacology 06/2015; 71(9). DOI:10.1007/s00228-015-1883-2 · 2.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
[Show abstract][Hide abstract] ABSTRACT: Aims: to investigate the prevalence of potentially inappropriate medication use among older people in Sweden according to five different published sets of explicit criteria from Europe and the US.
Methods: Nationwide cross-sectional, register-based study in the entire Sweden in 2008. All individuals aged 65 years and older were included (n = 1,346,709; both community-dwelling and institutionalized persons). We applied all drug-specific criteria included in the 2012 Beers Criteria, the Laroche's list, the PRISCUS list, the NORGEP criteria and the Swedish National Board of Health and Welfare criteria. Main outcome was the potentially inappropriate drug use according to each set of criteria, separately and combined. Multivariate logistic regression models were used to identify individual factors associated with the use of potentially inappropriate drugs.
Results: The prevalence of potentially inappropriate medication use varied between the explicit criteria from 16% (NORGEP criteria) to 24% (2012 Beers criteria). Overall, 38% of the older people were exposed to potentially inappropriate drug use by at least one of the five sets of criteria. While controlling for other possible covariates, female gender, institutionalisation and polypharmacy were systematically associated with inappropriate drug use, regardless of the set of explicit criteria we considered.
Conclusion: Although explicit criteria for inappropriate drug use among older people have been reported to be quite different in their content, they provide similar measures of the prevalence of potentially inappropriate drug use at the population level.
British Journal of Clinical Pharmacology 02/2015; 80(2). DOI:10.1111/bcp.12615 · 3.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Rationale, aims and objectivesAdverse drug reactions (ADRs) represent a major health problem and previous studies show that nurses can have an active role in promoting medication safety. The aim of this study was to describe and evaluate nurses' self-reported competence and pharmacovigilant activities in clinical practice and also to explore the impact of age, education, workplace and nursing experience on these matters.Methods
This cross-sectional study was based on a questionnaire covering areas related to nurses' medication competence, including knowledge, assessment and information retrieval, and pharmacovigilant activities within these areas, for example, the detection and assessment of ADRs. A 45-item questionnaire was 2013 sent out to 296 nurses in different settings and counties in Sweden. They were selected on the basis of having applied to a university course including pharmacovigilance during 2008-2011. One hundred twenty-four had participated in the courses (exposed) and 172 had applied to the courses but not participated (unexposed).ResultsCompleted questionnaires were obtained from 75 exposed (60%) and 93 unexposed (54%) nurses. Overall nurses rated themselves high in medication competence but low in pharmacovigilant activities. Significant (P ≤ 0.001) differences between groups were observed regarding medication competence. The exposure of completed dedicated courses in pharmacovigilance was the strongest factor for self-reported medication competence when adjusted for age, other education, workplace and experience. No significant differences between the groups were found regarding the number of pharmacovigilant activities during the 6 months prior to answering the questionnaire.Conclusion
Dedicated university courses improved nurses' self-reported competence in pharmacovigilance but did not increase the number of related activities. Education per se seems to be not sufficient to generate pharmacovigilant activities among nurses.
Journal of Evaluation in Clinical Practice 10/2014; 21(1). DOI:10.1111/jep.12263 · 1.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Mental disorders among older adults are mainly treated with psychotropic drugs. Few of these drugs are, however, prescribed by specialized geriatricians or psychiatrists, but rather from general practitioners (GPs). Socioeconomic inequalities in access to specialist prescribing have been found in younger age groups. Hence, we aimed to investigate whether there are socioeconomic differences in access to geriatrician and psychiatrist prescribing of psychotropic drugs among older adults.
By record-linkage of The Swedish Prescribed Drug Register and The Swedish Education Register, we obtained information for persons aged 75-89 years who had filled a prescription for psychotropic drugs (antipsychotics, anxiolytics, hypnotic/sedatives or antidepressants) with information on prescriber specialty from July to October 2005 (n = 221 579). Multinomial regression analysis was used to investigate whether education was associated with geriatrician and psychiatrist prescribing of psychotropic drugs.
The vast majority of the psychotropic drugs were prescribed by 'GPs and other specialists' (∼95% GPs). Older adults with higher educational level were more likely to be prescribed psychotropic drugs from psychiatrists and geriatricians. However, after adjustment for place of residence, the association between patient's education and prescription by a geriatrician disappeared, whereas the association with seeing a psychiatrist was only attenuated.
Access to specialized prescribing of psychotropics is unequally distributed between socioeconomic groups of older adults in Sweden. This finding was partially confounded by place of residence for geriatrician but not for psychiatrist prescribing. Further research should examine if inequalities in specialized psychotropic prescribing translate into worse outcomes for socioeconomically deprived and non-metropolitan-living older individuals.
The European Journal of Public Health 05/2014; 24(6). DOI:10.1093/eurpub/cku058 · 2.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Several measures of medication exposure are associated with adverse outcomes in older people. Exposure to and the clinical outcomes of these measures in robust versus frail older inpatients are not known.
In older robust and frail patients admitted to hospital after a fall, we investigated the prevalence and clinical impact of fall-risk-increasing drugs (FRIDs), total number of medications, and drug-drug interactions (DDIs).
Patients ≥60 years of age admitted with a fall to a tertiary referral teaching hospital in Sydney were recruited and frailty was assessed. Data were collected at admission, discharge, and 2 months after admission.
A total of 204 patients were recruited (mean age 80.5 ± 8.3 years), with 101 robust and 103 frail. On admission, compared with the robust, frail participants had significantly higher mean ± SD number of FRIDs (frail 3.4 ± 2.2 vs. robust 1.6 ± 1.5, P < 0.0001), total number of medications (9.8 ± 4.3 vs. 4.4 ± 3.3, P < 0.0001), and DDI exposure (35 vs. 5 %, P = 0.001). Number of FRIDs on discharge was significantly associated with recurrent falls [odds ratio (OR) 1.7 (95 % confidence interval [CI] 1.3-2.1)], which were most likely to occur with 1.5 FRIDs in the frail and 2.5 FRIDs in the robust. Number of medications on discharge was also associated with recurrent falls [OR 1.2 (1.0-1.3)], but DDIs were not.
Exposure to FRIDs and other measures of high-risk medication exposures is common in older people admitted with falls, especially the frail. Number of FRIDs and to a lesser extent total number of medicines at discharge were associated with recurrent falls.
[Show abstract][Hide abstract] ABSTRACT: There is substantial variability in the degree of cognitive impairment among older depressed persons. Inconsistencies in previous findings may be due to differences in clinical and demographic characteristics across study samples. We assessed the influence of unipolar depression and severity of depression on cognitive performance in a population-based sample of elderly persons aged ⩾60 years. Method Eighty-nine persons fulfilled ICD-10 criteria for unipolar depression (mild, n = 48; moderate, n = 38; severe, n = 3) after thorough screening for dementia (DSM-IV criteria), psychiatric co-morbidities and antidepressant pharmacotherapy. Participants (n = 2486) were administered an extensive cognitive test battery.
Moderate/severe unipolar depression was associated with poorer performance on tasks assessing processing speed, attention, executive function, verbal fluency, episodic memory and vocabulary. Mild depression was associated with poorer performance in processing speed, and few differences between mild and moderate/severe depression were observed. No association between depression and short-term memory, general knowledge or spatial ability was observed. Increasing age did not exacerbate the depression-related cognitive deficits, and the deficits remained largely unchanged after excluding persons in a preclinical phase of dementia. Furthermore, depression-related cognitive deficits were not associated with other pharmacological treatments that may affect cognitive performance.
Cognitive deficits in unipolar old-age depression involve a range of domains and the cognitive deficits seem to follow the spectrum of depression severity. The finding that mild depression was also associated with poorer cognitive functioning underscores the importance of detecting mild depression in elderly persons.
Psychological Medicine 07/2013; 44(5):1-11. DOI:10.1017/S0033291713001736 · 5.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: An association has been found between multi-dose drug dispensing (MDD) and use of many drugs. The aim of this study was to investigate the nature of this association, by performing a longitudinal analysis of the drug treatment before and after the transition to MDD.
Inclusion critera in this register-based study were inhabitants in Region Västra Götaland, Sweden, who, at ≥65 years of age and between 1(st) July 2006 and 30(th) June 2010, filled their first MDD prescription. For each individual, prescribed drugs were estimated at three month intervals before and after (maximum 3 years, respectively) the first date of filling an MDD prescription (index date).
A total of 30,922 individuals matched the inclusion criteria (mean age: 83.2 years; 59.9% female). There was a temporal association between the transition to MDD and an increased number of drugs: 5.4±3.9 and 7.5±3.8 unique drugs three months before and after the index date, respectively, as well as worse outcomes on several indicators of prescribing quality. When either data before or after the index date were used, a multi-level regression analysis predicted the number of drugs at the index date at 5.76 (95% confidence limits: 5.71; 5.80) and 7.15 (7.10; 7.19), respectively, for an average female individual (83.2 years, 10.8 unique diagnoses, 2.4 healthcare contacts/three months). The predicted change in the number of drugs, from three months before the index date to the index date, was greater when data before this date was used as compared with data after this date: 0.12 (0.09; 0.14) versus 0.02 (-0.01; 0.05).
After the patients entered the MDD system, they had an increased number of drugs, more often potentially harmful drug treatment, and fewer changes in drug treatment. These findings support a causal relationship between such a system and safety concerns as regards prescribing practices.
PLoS ONE 06/2013; 8(6):e67088. DOI:10.1371/journal.pone.0067088 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: One of the most common medical actions performed by a doctor is to prescribe medicine for a patient . In 2007, two in every three Swedes purchased at least one prescription drug at a pharmacy. The volume of drugs dispensed by pharmacies increases by 3-4 per cent every year. Recent years have seen the addition of a number of new and more effective drugs. The cost of prescription drugs rose by about 10 per cent annually in the period 1986-2002. However, the rate of increase has since slowed due to changes in the rules on pharmaceutical benefits, primarily those governing generic substitution. The combined cost of all medicines, i.e. prescription drugs, prescription- free drugs and drugs administered during hospital care, accounted for 11.6 per cent of total health and medical care costs in 2006. Pharmaceutical drug use patterns among women and men differ, as does drug use within social groups. Although these disparities are partly accounted for by variation in the disease burden across population groups, there are also gender and social disparities that cannot readily be attributed to differences in the needs of those who use prescription drugs. Examples include drugs for treating dementia and post-heart attack patients, which long-term follow-ups show are used more extensively by the highly educated than by the less well educated. People born outside the EU are less likely to use recommended medicines for heart attacks, heart failure, stroke and chronic obstructive pulmonary disease (COPD). The elderly are using prescription drugs to an increasing extent, a pattern that entails risks as well as benefits. A major proportion of the most frequently used drugs have a proven effect in treating many of the diseases and conditions common among the elderly. At the same time, use of multiple drugs, or polypharmacy, carries the risk of side effects and drug-drug interactions as different medications affect one another. The elderly are particularly vulnerable. Sensitive to drugs owing to dementia or multiple morbidity, they are among those most often exposed to polypharmacy. As a result, drug treatment is not always entirely appropriate. The Swedish National Board of Health and Welfare has accordingly developed quality indicators  and assessed and discussed the quality of drug treatments for the elderly in a number of reports [3-5]. According to the World Health Organization (WHO), deficiencies in drug prescribing are a principal cause of inadequate clinical treatment .
Scandinavian Journal of Public Health 12/2012; 40(9 Suppl):293-304. DOI:10.1177/1403494812459623 · 1.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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).
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.
Institutionalized elderly were more likely than community-dwelling elderly to use antidepressants, laxatives, minor analgesics, opioids and hypnotics/sedatives, 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.
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.
[Show abstract][Hide abstract] ABSTRACT: Purpose:
We compared the quality and pattern of use of antibiotics to treat urinary tract infection (UTI) between institutionalized and home-dwelling elderly.
We analyzed the quality of use of UTI antibiotics in Swedish people aged ≥ 65 years at 30 September 2008 (1,260,843 home-dwelling and 86,721 institutionalized elderly). Data regarding drug use, age and sex were retrieved from the Swedish Prescribed Drug Register and information about type of housing from the Social Services Register. In women, we assessed: (1) the proportion who use quinolones (should be as low as possible); (2) the proportion treated with the recommended drugs (pivmecillinam, nitrofurantoin, or trimethoprim) (proportions should be about 40 %, 40 % and 15-20 %, respectively); In men, we assessed: (1) the proportion who used quinolones or trimethoprim (should be as high as possible).
The 1-day point prevalence for antibiotic use for UTI was 1.6 % among institutionalized and 0.9 % among home-dwelling elderly. Of these, about 15 % of institutionalized and 19 % of home-dwelling women used quinolones. The proportion of women treated with the recommended drugs pivmecillinam, nitrofurantoin or trimethoprim was 29 %, 27 % and 45 % in institutions and 40 %, 28 % and 34 % for home-dwellers. In men treated with antibiotics for UTI, quinolones or trimethoprim were used by about 76 % in institutions and 85 % in home-dwellers.
Our results indicate that recommendations for UTI treatment with antibiotics are not adequately followed. The high use of trimethoprim amongst institutionalized women and the low use of quinolones or trimethoprim among institutionalized men need further investigation.
European Journal of Clinical Pharmacology 08/2012; 69(3). DOI:10.1007/s00228-012-1374-7 · 2.97 Impact Factor