Potentially inappropriate prescribing in older patients discharged from acute care hospitals to residential aged care facilities

Background The frequency of prescribing potentially inappropriate medications (PIMs) in older patients remains high despite evidence of adverse outcomes from their use. Little is known about whether admission to hospital has any effect on appropriateness of prescribing. Objectives This study aimed to identify the prevalence and nature of PIMs and explore the association of risk factors for receiving a PIM. Methods This was a prospective study of 206 patients discharged to residential aged care facilities (RACFs) from acute care. All patients were aged at least 70 years and were admitted between July 2005 and May 2010; their admission and discharge medications were evaluated. Results Mean patient age was 84.8 ± 6.7 years; the majority (57%) were older than 85 years and mean (SD) Frailty Index was 0.42 (0.15). At least one PIM was identified in 112 (54.4%) patients on admission and 102 (49.5%) patients on discharge. Of all medications prescribed at admission (1728), 10.8% were PIMs and at discharge of 1759 medications, 9.6% were PIMs. Of total 187 PIMs on admission, 56 (30%) were stopped and 131 were continued; 32 new PIMs were introduced. Of the potential risk factors considered, in-hospital cognitive decline and frailty status were the only significant predictors of PIMs. Conclusion Although, admission to hospital is an opportunity to review the indications for specific medications, a high prevalence of inappropriate drug use was observed. The only associations with PIM use were the frailty status and in-hospital cognitive decline. Additional studies are needed to further evaluate this association.

Potentially inappropriate prescribing in older patients admitted to acute care hospitals and discharged to residential aged care facilities

Background The frequency of prescribing potentially inappropriate medications (PIMs) in older patients remains high regardless of the evidence of adverse outcomes from their use. This study aims to identify the prevalence and nature of PIMs at admission to acute care and at discharge to residential aged care facilities (RACFs) using the recently updated Beers’ Criteria. We also aim to identify if polypharmacy, age, gender and the frailty status of patients are independent risk factors for receiving a PIM. Methods This was a retrospective study of 206 patients discharged to RACFs from acute care. All patients were aged at least70 years and were admitted between July 2005 and May 2010; their admission and discharge medications were evaluated. Frailty status was measured as the Frailty Index (FI), adding each individual’s deficits and dividing by the total number of deficits considered, with FI 0.25 used as the cut-off between “fit” and “frail”. Results Mean patient age was 84.8 ± 6.7 years; the majority (57%) were older than 85 years and approximately 90% were frail. Patients were prescribed a mean of 7.2 regular medications at admission and 8.1 on discharge. At least one PIM was identified in 112 (54.4%) patients on admission and 102 (49.5%) patients on discharge. Of all medications prescribed at admission (1728), 10.8% were PIMs and at discharge of 1759 medications, 9.6% were PIMs. Of the total 187 PIMs on admission, 56 (30%) were stopped, and 131 were continued; 32 new PIMs were introduced. Commonly prescribed PIMs at both admission and discharge were central nervous system, cardiovascular and gastrointestinal drugs and analgesics. Of the potential risk factors, frailty status was the only significant predictor of PIMs at both admission and discharge (p = 0.016). Conclusion A high prevalence of unnecessary drug use was observed in frail older patients on admission to acute care hospitals and on discharge to RACFs. The only association with PIM use was the frailty status of patients. Further studies are needed to further evaluate this association.

The impact of frailty and polypharmacy on adverse outcomes in older inpatients

Background Older people are at significant risk of adverse outcomes as a result of changes in physiology, frailty, co-morbidity and polypharmacy.1 Timely identification of high-risk patients may facilitate the optimization of medication and reduce the incidence of adverse outcomes. The aims of this study were to evaluate in older inpatients the relationships between risk factors, including frailty and polypharmacy, and adverse health outcomes. Methods This is a prospective study of 1418 patients, aged 70 and older, admitted to general medical units in 11 acute care hospitals across Australia. The interRAI Acute Care (interRAI AC) assessment tool was used for data collection. Frailty status was measured using a Frailty Index (FI), adding each individual’s deficits and dividing by the total number of deficits considered. Adverse health outcomes included falls in hospital, delirium, in-hospital functional and cognitive decline, discharge to a higher level of care and inpatient mortality. Results Patients had a mean age 81 ± 6.8 years with a median length of hospital stay of 6 days (interquartile range 4 to 11 days); 701 (50%) experienced at least one adverse outcome. Polypharmacy (5-9 drugs per day) was observed in almost half of the study population (n=695, 49%) and hyper-polypharmacy (≥10 drugs) observed in about one-third of patients (n=490, 34.6%). Cognitive impairment was shown to be associated with the lower rate of prescribing. FI had a significant association with all adverse outcomes studied (p = <0.05). In contrast, no association was observed between polypharmacy categories and adverse outcomes except for those on 10 or more drugs where they were more likely to be discharged to a higher level of care (p= 0.014). Conclusions Among older inpatients, frailty status was a significant predictor of adverse outcomes. Lower rates of prescribing to patients with cognitive impairment may underpin the lack of an association between polypharmacy and adverse outcomes in this cohort. References: 1. Olsson IN, Runnamo R, Engfeldt P. Medication quality and quality of life in the elderly, a cohort study.Health Qual Life Outcomes.2011;9:95

A New Mechanism For Ferromagnetism In C-60-TDAE

Based on the topology of C-60 and the resulting non-disjoint nature of the lowest unoccupied molecular orbitals, Ne propose a new model for ferromagnetic exchange in C-60-TDAE. Within the Hubbard model, we find that the ferromagnetic exchange integral is stabilized to first order in the inter-ball transfer integral, while the antiferromagnetic coupling is stabilized only to second order. This difference is adequate to counter the larger phase space available for stabilizing the antiferromagnetic state. Thus, the ground state is found to be ferromagnetic for reasonable inter-ball transfer integrals.

Electronic structure of La1-xSrxCrO3

LaCrO3 is a wide-band-gap insulator which does not evolve to a metallic state even after hole doping. We report electronic structure of this compound and its Sr substituents investigated by photoemission and inverse photoemission spectroscopies in conjunction with various calculations. The results show that LaCrO 3 is close to the Mott-Hubbard insulating regime with a gap of about 2.8 eV. Analysis of Cr 2p core-level spectrum suggests that the intra-atomic Coulomb interaction strength and the charge-transfer energy to be 5.0 and 5.5 eV, respectively, We also estimate the intra-atomic exchange interaction strength and a crystal-field splitting of about 0.7 and 2.0 eV, respectively. Sr substitution leading to hole doping in this system decreases the charge-excitation gap, but never collapses it to give a metallic behavior. The changes in the occupied as well as unoccupied spectral features are discussed in terms of the formation of local Cr4+ configurations arising from strong electron-phonon interactions.

Unoccupied electronic states in NiS2-xSex across the metal-insulator transition

We investigate the evolution of the electronic structure across the insulator-metal transition in NiS2-xSex with changing composition, but in the absence of any structural or magnetic changes. A comparison of the inverse photoemission spectra with band-structure calculations establishes the importance of correlation effects in these systems. Systematic changes in the spectral distribution establish the persistence of the upper Hubbard band well into the metallic regime, with the insulator-to-metal transition being driven by a transfer of spectral weight from the Hubbard band to states close to the Fermi energy.

Effects of Low Dose Irradiation on the K-Value and Hypoxanthine Concentration of Fish Fillets

Fillets of five fish species were irradiated at 0, 1 and 3kGy to investigate whether the K-value test of freshness can be applied to irradiated fish. Following irradiation, the fillets were stored on ice and sampled regularly for K-value analysis. Hypoxanthine (Hx) and total nucleotide content were also determined on fillets of two species. K-values of irradiated fillets were generally lower than those of unirradiated controls. Hypoxanthine levels paralleled the K-value changes. These results indicated that quality standards based on K-values or Hx levels that have been set for unirradiated species cannot be directly applied to fish that has been irradiated. Total nucleotide content did not appear to be affected by irradiation.

Theoretical description of time-resolved pump/probe photoemission in TaS2: a single-band DFT+DMFT(NRG) study within the quasiequilibrium approximation

In this work, we theoretically examine recent pump/probe photoemission experiments on the strongly correlated charge-density-wave insulator TaS2.We describe the general nonequilibrium many-body formulation of time-resolved photoemission in the sudden approximation, and then solve the problem using dynamical mean-field theory with the numerical renormalization group and a bare density of states calculated from density functional theory including the charge-density-wave distortion of the ion cores and spin-orbit coupling. We find a number of interesting results: (i) the bare band structure actually has more dispersion in the perpendicular direction than in the two-dimensional planes; (ii) the DMFT approach can produce upper and lower Hubbard bands that resemble those in the experiment, but the upper bands will overlap in energy with other higher energy bands; (iii) the effect of the finite width of the probe pulse is minimal on the shape of the photoemission spectra; and (iv) the quasiequilibrium approximation does not fully describe the behavior in this system.

Radish sprouts versus broccoli sprouts: a comparison of anti-cancer potential based on glucosinolate breakdown products.

Radish sprouts and broccoli sprouts have been implicated in having a potential chemoprotective effect against certain types of cancer. Each contains a glucosinolate that can be broken down to an isothiocyanate capable of inducing chemoprotective factors known as phase 2 enzymes. In the case of broccoli, the glucosinolate, glucoraphanin, is converted to an isothiocyanate, sulforaphane, while in radish a similar glucosinolate, glucoraphenin, is broken down to form the isothiocyanate, sulforaphene. When sprouts are consumed fresh (uncooked), however, the principal degradation product of broccoli is not the isothiocyanate sulforaphane, but a nitrile, a compound with little anti-cancer potential. By contrast, radish sprouts produce largely the anti-cancer isothiocyanate, sulforaphene. The reason for this difference is likely to be due to the presence in broccoli (and absence in radish) of the enzyme cofactor, epithiospecifier protein (ESP). In vitro induction of the phase 2 enzyme, quinone reductase (QR), was significantly greater for radish sprouts than broccoli sprouts when extracts were self-hydrolysed. By contrast, boiled radish sprout extracts (deactivating ESP) to which myrosinase was subsequently added, induced similar QR activity to broccoli sprouts. The implication is that radish sprouts have potentially greater chemoprotective action against carcinogens than broccoli sprouts when hydrolysed under conditions similar to that during human consumption.

Hole Pairing In Antiferromagnetically Correlated Layered Oxides

We have considered a two-band Hubbard model having interlaced Cu-3d(x2−y2) and O-2p(x, y) orbitals representing the CuO2 square planes. Simple CuO2 -cluster calculation suggests that the additional holes created by doping stay mainly on oxygen. Motion of an oxygen hole interlacing with the antiferromagnetically correlated background of copper spins, creates a string of high energy spin configuration of finite length giving mass renormalization. Another hole of opposite spin can now anneal this string tension providing a triangular pairing potential for large pair momentum. The latter implies unusual Bose condensation of the wake-bound compact Bose-like pairs on a non-zero momentum shell. Effect of disorder favouring condensation at the mobility edge is pointed out.

Specific detection of the Old World screwworm fly, Chrysomya bezziana, in bulk fly trap catches using real-time PCR.

The Old World screwworm fly (OWS), Chrysomya bezziana Villeneuve (Diptera: Calliphoridae), is a myiasis-causing blowfly of major concern for both animals and humans. Surveillance traps are used in several countries for early detection of incursions and to monitor control strategies. Examination of surveillance trap catches is time-consuming and is complicated by the presence of morphologically similar flies that are difficult to differentiate from Ch. bezziana, especially when the condition of specimens is poor. A molecular-based method to confirm or refute the presence of Ch. bezziana in trap catches would greatly simplify monitoring programmes. A species-specific real-time polymerase chain reaction (PCR) assay was designed to target the ribosomal DNA internal transcribed spacer 1 (rDNA ITS1) of Ch. bezziana. The assay uses both species-specific primers and an OWS-specific Taqman MGB probe. Specificity was confirmed against morphologically similar and related Chrysomya and Cochliomyia species. An optimal extraction protocol was developed to process trap catches of up to 1000 flies and the assay is sensitive enough to detect one Ch. bezziana in a sample of 1000 non-target species. Blind testing of 29 trap catches from Australia and Malaysia detected Ch. bezziana with 100% accuracy. The probability of detecting OWS in a trap catch of 50 000 flies when the OWS population prevalence is low (one in 1000 flies) is 63.6% for one extraction. For three extractions (3000 flies), the probability of detection increases to 95.5%. The real-time PCR assay, used in conjunction with morphology, will greatly increase screening capabilities in surveillance areas where OWS prevalence is low.

DFT study of electronic and optical properties of anatase titanium dioxide tuned by nitrogen and lithium co-doping

The electronic and optical properties of anatase titanium dioxide (TiO2), co-doped by nitrogen (N) and lithium (Li), have been investigated by density functional theory plus Hubbard correction term U, namely DFT+U. It is found that Li-dopants can effectively balance the net charges brought by N-dopants and shift the local state to the top of valence band. Depending on the distribution of dopants, the adsorption edges of TiO2 may be red- or blue-shifted, being consistent with recent experimental observations.

Algorithm of medication review in frail older people: Focus on minimizing the use of high-risk medications

Aim Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high-risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high-risk medications. Methods The literature was searched for robust evidence of the association of adverse effects related to potentially inappropriate medications in older patients to identify high-risk medications. Prior research into the cessation of potentially inappropriate medications in older patients in different settings was synthesized into a four-step algorithm for incorporation into clinical assessment protocols for patients, particularly those in residential aged care facilities. Results The algorithm comprises several steps leading to individualized prescribing recommendations: (i) identify a high-risk medication; (ii) ascertain the current indications for the medication and assess their validity; (iii) assess if the drug is providing ongoing symptomatic benefit; and (iv) consider withdrawing, altering or continuing medications. Decision support resources were developed to complement the algorithm in ensuring a systematic and patient-centered approach to medication discontinuation. These include a comprehensive list of high-risk medications and the reasons for inappropriateness, lists of alternative treatments, and suggested medication withdrawal protocols. Conclusions The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes.

Geriatrician interventions on medication prescribing for frail older people in residential aged care facilities

Objective: In Australian residential aged care facilities (RACFs), the use of certain classes of high-risk medication such as antipsychotics, potent analgesics, and sedatives is high. Here, we examined the prescribed medications and subsequent changes recommended by geriatricians during comprehensive geriatric consultations provided to residents of RACFs via videoconference. Design: This is a prospective observational study. Setting: Four RACFs in Queensland, Australia, are included. Participants: A total of 153 residents referred by general practitioners for comprehensive assessment by geriatricians delivered by video-consultation. Results: Residents’ mean (standard deviation, SD) age was 83.0 (8.1) years and 64.1% were female. They had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean (SD) of 9.6 (4.2) regular medications. Ninety-one percent of patients were taking five or more medications daily. Of total medications prescribed (n=1,469), geriatricians recommended withdrawal of 9.8% (n=145) and dose alteration of 3.5% (n=51). New medications were initiated in 47.7% (n=73) patients. Of the 10.3% (n=151) medications considered as high risk, 17.2% were stopped and dose altered in 2.6%. Conclusion: There was a moderate prevalence of potentially inappropriate high-risk medications. However, geriatricians made relatively few changes, suggesting either that, on balance, prescription of these medications was appropriate or, because of other factors, there was a reluctance to adjust medications. A structured medication review using an algorithm for withdrawing medications of high disutility might help optimize medications in frail patients. Further research, including a broader survey, is required to understand these dynamics.

Age-related changes in hepatic function: An update on implications for drug therapy

The accumulation of deficits with increasing age results in a decline in the functional capacity of multiple organs and systems. These changes can have a significant influence on the pharmacokinetics and pharmacodynamics of prescribed drugs. Although alterations in body composition and worsening renal clearance are important considerations, for most drugs the liver has the greatest effect on metabolism. Age-related change in hepatic function thereby causes much of the variability in older people’s responses to medication. In this review, we propose that a decline in the ability of the liver to inactivate toxins may contribute to a proinflammatory state in which frailty can develop. Since inflammation also downregulates drug metabolism, medication prescribed to frail older people in accordance with disease-specific guidelines may undergo reduced systemic clearance, leading to adverse drug reactions, further functional decline and increasing polypharmacy, exacerbating rather than ameliorating frailty status. We also describe how increasing chronological age and frailty status impact liver size, blood flow and protein binding and enzymes of drug metabolism. This is used to contextualise our discussion of appropriate prescribing practices. For example, while the general axiom of ‘start low, go slow’ should underpin the initiation of medication (titrating to a defined therapeutic goal), it is important to consider whether drug clearance is flow or capacity-limited. By summarising the effect of age-related changes in hepatic function on medications commonly used in older people, we aim to provide a guide that will have high clinical utility for practising geriatricians.