Polypharmacy in older adults: the role of the multidisciplinary team

ABSTRACT

Patients over the age 65 are a quickly expanding segment of the US population and represent a large percentage of patients requiring inpatient care. Older adults are more likely to experience polypharmacy and adverse drug effects. This review explains the risks of polypharmacy and potentially inappropriate medications in the elderly. Specific classes of medications frequently used in older adults in acute care settings are examined, including anticholinergic, sedative hypnotics, and antipsychotic medications. We discuss strategies aimed at addressing polypharmacy in this population including a drug regimen review (which is distinct from medication reconciliation), screening tools, pharmacist-led interventions, and computer-based strategies in the context of current literature and research findings. We provide a summary of general guidelines that may be helpful for geriatricians and hospitalists in improving patient care and clinical outcomes.     

Multidisciplinary diabetes team care: the experiences of young adults with Type 1 diabetes

Background

This research examined whether young adults with Type 1 diabetes engage with the multidisciplinary consultation process and if not, then why.

Methods

We designed a web‐based self‐reported survey, available online from February to May 2011, for Australian adults 18–35 years with Type 1 diabetes. Respondents were asked about which clinicians they consulted to assist with self‐management. To expand on the results of the survey, we interviewed 33 respondents.

Results

Survey: Respondents (n = 150) consulted with the following clinicians: endocrinologist and diabetes educators: 23.3%; endocrinologist only: 18.0%; endocrinologist, diabetes educators and dieticians: 14.6%; endocrinologist, diabetes educators, dietician and general practitioners (GP): 11.3%; endocrinologist and GP: 10.6%; GP only: 4.6%; all clinicians recommended to assist with self‐management: 1.3%; 2.7% did not consult any clinician. Interview: Participants (n = 33) reported eight key disincentives to consultation with multidisciplinary clinicians. These were time constraints; provision of conflicting advice; inaccessibility of health services; variation in service standards; cost constraints; failure of clinicians to refer to other clinicians; lack of opportunity to build a therapeutic relationship; and failure of clinicians to engage in shared decision making.

Conclusion

Our results indicate that high attrition rates of young adults with Type 1 diabetes from recommended diabetes health services is linked to the failure of those services to meet the needs and preferences of their patients. The identified needs and preferences included joint consultation with multi‐disciplinary team clinicians; flexible access to advice by email or telephone consultation; and shared decision making. Patient engagement in health‐service re‐design has implications for improved health‐service delivery and enhanced treatment outcomes.     

Frailty status is related to general and abdominal obesity in older adults

The association between frailty and obesity may differ according to the heterogeneity of body mass index (BMI) and waist circumference (WC) phenotypes in older adults. We hypothesized that the use of simple indicators of general and abdominal obesity combined, may more accurately represent obesity and allow to further elucidate on how frailty status and its criteria are related to obesity. A sample of 1444 older adults, aged ≥65 years (Nutrition UP 65 study) was included in a cross-sectional analysis. General and abdominal obesity were defined according to World Health Organization BMI and WC cut-offs, and frailty by Fried et al. phenotype. A cluster analysis defined groups according to BMI and WC levels. Overweight (BMI between 25.0 and 29.9 kg/m²; 44.6%), general obesity (BMI ≥30.0 kg/m²; 39.0%), and abdominal obesity (WC >102 cm for men and >88 cm for women) were highly frequent (66.5%). Prefrailty (odds ratio [OR]: 2.33; 95% confidence interval [CI]: 1.52-3.57) and frailty (OR: 2.87; 95% CI: 1.58-5.22) were directly associated with the “general and abdominal obesity” cluster. Regarding frailty criteria, low handgrip strength (OR: 2.29; 95% CI: 1.55-3.38) and weight loss (OR: 0.27; 95% CI: 0.14-0.52) were also associated with this cluster. In this sample of older adults presenting a high frequency of overweight and obesity, prefrailty and frailty are linked to higher levels of adiposity, but only when both general and abdominal obesity are present. Present results emphasize the importance of the evaluation of both BMI and WC in the geriatric clinical practice and suggest that older adults presenting both general and abdominal obesity should be routinely screened for frailty.     

Multilevel modelling of built environment characteristics related to neighbourhood walking activity in older adults

OBJECTIVE: To examine the relation between built environment factors (representing several dimensions of urban form of neighbourhoods) and walking activity at both the neighbourhood level and the resident level, in an older adult sample. DESIGN, SETTING, PARTICIPANTS: A cross sectional, multilevel design with neighbourhoods as the primary sampling unit and senior residents as the secondary unit. Five hundred and seventy seven residents (mean age = 74 years, SD = 6.3 years) participated in the survey, which was conducted among 56 city defined neighbourhoods in Portland, Oregon, USA. Neighbourhood level variables were constructed using geographical information systems. Resident level variables consisted of a mix of self reports and geocoded data on the built environment. MAIN OUTCOME MEASURE: Self reported neighbourhood walking. MAIN RESULTS: A positive relation was found between built environment factors (density of places of employment, household density, green and open spaces for recreation, number of street intersections) and walking activity at the neighbourhood level. At the resident level, perceptions of safety for walking and number of nearby recreational facilities were positively related to high levels of walking activity. A significant interaction was observed between number of street intersections and perceptions of safety from traffic. CONCLUSIONS: Certain neighbourhood built environment characteristics related to urban form were positively associated with walking activity in the neighbourhoods of senior residents. Public health promotion of walking activity/urban mobility and the design of interventions need to consider the contribution of neighbourhood level built environment influences.     

A team approach to OR environmental issues

At Munroe Regional Medical Center in Ocala, FL, an effective partnership between Materials Management and the Operating Room was begun by building consensus around a shared concern--minimizing the Operating Room's impact on the environment. To accurately evaluate cost-in-use issues, Materials Management and the OR needed a better understanding of each other's processes, procedures and decision-making criteria. Materials Management observed surgical procedures to understand product requirements, and OR personnel were given financial information on such matters as group purchasing and disposal costs. After considering all the data, the MM/OR team decided to continue using single-use polypropylene gowns rather than switch to reusable gowns. Success in this endeavor led the team to institute a disposable wrap recycling program. Lasting benefits of the collaboration include higher cost consciousness among clinicians, open communications, greater supplier accountability for cradle-to-grave cost estimates and team building.     

Administrative issues related to addiction in the workplace

Drug abuse is an important problem in the workplace. Seventy percent of current illegal drug users are employed, and approximately 7% of Americans employed in full-time work report heavy drinking. Drug-using employees are twice as likely to request time off, and 3.6 times more likely to be involved in a workplace accident. Individuals who use alcohol or other drugs in the workplace annually cost American business 81 billion dollars in lost productivity; 86% of these costs are attributed to drinking. Although alcohol is the primary source of problems for the workplace, other drugs such as amphetamines, cocaine, marijuana, and tobacco are also troublesome. Employee assistance programs and drug treatment hold great promise for coping with these problematic substances.     

Knowledge,attitudes and practices related to the influenza virus and vaccine among older adults in Eastern China

BackgroundThis study aims to assess the association between socio-demographic and health characteristics of older adults in Eastern China and knowledge, attitudes, and practices (KAP) about the influenza virus and vaccine.MethodsA prospective cohort of 1506 older adults (aged ≥60 years) was enrolled from November to December 2015 in Jiangsu Province. We examined the association between demographics, health and functional status, and cognitive impairment at enrollment with awareness of influenza virus and vaccine and KAP items focused on five Health Belief Model domains. At a 12-month follow-up interview we assessed change in awareness and readiness to be vaccinated.ResultsOne in five older adults was aware of the influenza virus (21%) or vaccine (20%); even fewer reported having at least “a little” knowledge of the virus and vaccine (7% and 4%, respectively); less than 1% reported ever receiving an influenza vaccine. Retirement, higher education and income, and normal cognitive status were consistently associated with both awareness and knowledge of influenza virus. The odds of having at least “a little” knowledge of the vaccine was 2.9-fold (95% CI = 1.6–5.3) higher among older adults with at least some secondary schooling. Among the 108 with knowledge of the virus, 55% said they “worry about getting the flu this season.” Among the 73 with knowledge of the vaccine, 92% believed the vaccine was at least somewhat effective and less than half (43%) thought that influenza vaccination was safe. At a 12-month follow-up interview, 33% (442/1333) increased from no knowledge to at least “a little”.ConclusionsIf and when influenza vaccines become widely available to older adults in China, our results indicate that influenza vaccination campaigns with basic information on the virus and vaccine could be beneficial for all older adults, especially those with less education and/or more cognitive impairment.     

Elevated methylmalonic acid is related to cognitive impairement in older adults enrolled in an elderly nutrition program

Vitamin B12 status has been linked to cognitive impairment among older adults. Deficit in methylmalonic acid (MMA) may be reflective of cognitive impairment because it is a biochemically sensitive marker of B12 deficiency. In a cross-sectional study the contributions of different indices of B12 status, including serum B12, MMA and total homocysteine (tHcy), were measured in relation to cognitive functioning. B12 deficiency as measured by elevated MMA concentrations appeared to be most reflective of cognitive impairment and appeared to contribute unique variance to cognitive measures after controlling for other biochemical variables. Demographic variables, particularly education and age, were more strongly associated with cognitive measures than was MMA. Monitoring and reducing serum MMA concentrations by increasing the intake of vitamin B12 may provide protection against cognitive decline in this and other older populations.     

Transitions of older adults to home care

To discover the process of admission and transition of older adults to home care following hospital discharge, or during periods of illness, ethnographic methodology was used to explore the experience of 65 participants in the "culture" of home care: patients, families, nurses, home care staff, and discharge planners. Two themes resulting from ethnographic analysis are presented: identification of patients and needs, and transfer of information. Support from family and friends was an essential addition to referral by discharge planners, physicians, and casefinding in facilitating transition to home care. Accurate, timely patient information was found to expedite home nursing assessment and insure continuity of care.     

Comparison between Kanagawa Prefecture and Ohio state of factors related to health behavior among older adults

Factors related to health behavior of older adults in Japan and the United States were compared. A total of 900 persons from three age groups (45 to 59, 60 to 74 and 75 and over) were interviewed in three communities (major metropolitan, midsized city, and small town), in both Kanagawa Prefecture and Ohio State. To determine the reliability of the results, in addition to analysis for all subjects, each of communities were analyzed separately. Health behaviors were divided into 2 separate levels: 1) preventive health behaviors and 2) coping behaviors for symptoms which may be signs of a serious illness. The latter behaviors were classified into three types: 1) seeing a physician, 2) changing lifestyle and 3) taking OTC drugs. The following results were obtained: 1) In both Kanagawa Prefecture and Ohio State, good preventive health behaviors were unrelated to coping behaviors associated with potentially serious illness. Interviewees who used OTC drugs when experiencing a potentially serious illness had a low tendency toward seeing a physician. In Kanagawa Prefecture, individuals who saw a physician showed a strong tendency toward changing their lifestyle, for symptoms which were potential signs of a serious illness. 2) There were some differences in factors related to preventive health behaviors between Kanagawa Prefecture and Ohio State. In Kanagawa Prefecture, there were sex differences, with males exhibiting preventive health behaviors. In Ohio State, good preventive health behaviors were few among interviewees who were black. 3) There was little difference between Kanagawa and Ohio State as far as the tendency toward seeing a physician when experiencing potentially serious illness. In both places, interviewees with good self-rated health status and having strong self-treatment attitudes showed a lower tendency to see a physician when experiencing symptoms which were potential signs of a serious illness.     

Barriers and motivations to exercise in older adults

Although exercise is an established component in the management of many chronic diseases associated with aging, activity levels tend to progressively decline with increasing age. Given the growing proportion of older adults, these suboptimal levels of physical activity represent an increasing public health problem. The predicators of adherence elucidated in younger adults are unreliable in elderly populations. Age-specific barriers and motivators unique to this cohort are relevant and must be acknowledged. The identification of reliable predictors of exercise adherence will allow healthcare providers to effectively intervene and change patterns of physical activity in sedentary elderly. In particular, because older patients respect their physician's advice and have regular contact with their family doctor, physicians can play a key and pivotal role in the initiation and maintenance of exercise behavior among the older population.     

Examining variables related to successful collaboration on the hospice team

Although social work participation on interdisciplinary teams is long-standing, little research has been done to examine its effectiveness. This study used the Index of Interdisciplinary Collaboration to explore relationships between selected variables and teamwork in the hospice setting.The findings indicate that hospice social workers report a high level of interdisciplinary collaboration with colleagues. Whereas education, hospice census, the presence of other social workers, and quality of care were found to be unrelated to overall levels of collaboration, individual items measuring collaboration proved to be linked with hospice census, the presence of other social workers on the team, and quality of care. Further research is required to investigate other possible related variables and their impact on successful interdisciplinary collaboration and service delivery.     

Physical activity and functional limitations in older adults: a systematic review related to Canada's Physical Activity Guidelines

Background  

The purpose was to conduct systematic reviews of the relationship between physical activity of healthy community-dwelling older (>65 years) adults and outcomes of functional limitations, disability, or loss of independence.