Changes in Drug Use and Polypharmacy After the Age of 90:A Longitudinal Study of the Danish 1905 Cohort

Objectives: To determine the longitudinal development of drug use in very old adults. Design: Longitudinal cohort study with waves in 1998, 2000, 2002, and 2005. Setting: Nationwide study in Denmark. Participants: All living Danes born in 1905 were approached in 1998; 2,262 responded at baseline. Measurements: Self-reported use of regularly taken drugs. Mean and median number of drugs and growth curve models were used to identify the change in number of drugs as the cohort aged from 92 to 100. Results: The within-person use of drugs increased with age for women (0.19 per year; 95% confidence interval (CI) = 0.15–0.24) and men (0.15 per year; 95% CI = 0.06–0.24). Persons leaving the study prematurely had higher baseline values and a steeper increase in their annual use of drugs. The population-level mean number of drugs increased from baseline (3.6 drugs) to the first follow-up (4.1 drugs) but thereafter remained stable at approximately 4 drugs. Women used more drugs than men at all waves. Conclusion: In this first longitudinal study of drug use in nonagenarians, individuals used an increasing number of drugs as they aged. This increase is difficult to detect in cross-sectional analyses of the population-level mean. More efforts to understand what is reasonable prescribing at these older ages are needed.</p

Unequal drug treatment : age and educational differences among older adults

The overall aim of this thesis is to investigate whether drug treatment is unequally distributed among older adults on the basis of age and socioeconomic position. All studies in this thesis are based on nationwide register data from the Swedish Prescribed Drug Register (SPDR) record-linked to other registers in Sweden. In Study I, we investigated differences in drug use between centenarians (≥100 years; n=1,672), nonagenarians (90-99 years; n=76,584) and octogenarians (80-89 years; n=383,878). The results showed that the proportion of people living in institutions increased with age, but the number of drugs was similar across the age groups. Centenarians were more likely to use psychotropics (hypnotics/sedatives, antidepressants and anxiolytics) and pain killers (minor analgesics and opioids). This might indicate that drug treatment has a more palliative character in centenarians than in the other age groups. Centenarians used older types of cardiovascular drugs which could reflect a lack of regular re-evaluation of drug use in centenarians or a disinclination to make changes in well-functioning drug therapy among the extremely old. The aim of Study II was to investigate educational differences (as a measure of socioeconomic position) in osteoporosis drug use before and after osteoporosis-related fractures among persons aged 75-89 years (n=645,429). There is a general underuse of osteoporosis drugs among older adults in Sweden. Our results suggest that older persons with lower levels of education are less likely to receive drug treatment both before and after an osteoporosis-related fracture (only statistically significant in women) than their more highly educated counterparts. The educational differences were more pronounced for newer and more potent osteoporosis drug treatments. Lower socioeconomic position seems to be linked to a lower use of osteoporosis drugs – a drug therapy that is generally underused. In Study III, the aim was to investigate educational differences in antipsychotic drug use among older adults (aged 75-89 years) with and without dementia (n=641,566). Antipsychotic drugs are commonly used to treat behavioral and psychological symptoms of dementia, but the use of these drugs has been associated with increased morbidity and mortality. Efforts have therefore been made to reduce the prescribing of antipsychotic drugs to older adults with dementia. We found a higher use of antipsychotic drugs among persons with lower levels of education, both among persons with and without dementia. Lower socioeconomic position seems to be positively associated with a higher use of antipsychotic drugs – a drug therapy that is generally overused. We investigated educational differences in being prescribed psychotropic drugs by specialist physicians among older (aged 75-89 years) psychotropic drug users (n=221,579) in Study IV. Higher levels of education were associated with more access to geriatrician and psychiatrist prescribing. However, when place of residence was taken into account, the association between higher education and psychotropic prescription by geriatricians became non-significant, whereas the association between higher education and prescription by psychiatrists persisted. Limited access to specialists could be one mechanism liking lower socioeconomic position to less optimal drug treatment. This thesis contributes to a better understanding of how socioeconomic position and age are related to drug use. In general, lower socioeconomic position and older age seem to be associated with less optimal drug treatment. However, the mechanisms behind these findings are probably complex and need to be addressed in further research to provide a foundation for social polic

How chronic is polypharmacy in old age? A longitudinal nationwide cohort study

OBJECTIVE: To evaluate the chronicity of polypharmacy among older adults, and to identify factors associated with chronic polypharmacy. DESIGN: Longitudinal cohort study using register data. SETTING: Nationwide, Sweden. PARTICIPANTS: All 711,432 older adults (≥65 years) living in Sweden with 5 or more prescription drugs in October 2010 were included and followed-up until December 2013. Mean age at baseline was 77 (SD, 7.8) years, 59% were women, and 7% lived in nursing homes. MEASUREMENT: Monthly changes in the exposure to polypharmacy. Data regarding prescription drug use were extracted from the Swedish Prescribed Drugs Register. RESULTS: Overall, 82% were continuously exposed to polypharmacy during ≥6 months, and 74% during ≥12 months. The proportion of individuals who remained exposed until the end of the study was 55%. Among the 21,361 individuals who had not been exposed to polypharmacy during the 6-month period before baseline (i.e. with a new episode of polypharmacy), only 30% remained exposed for ≥6 months. The proportion of older adults who spent at least 80% of their follow-up time with polypharmacy was substantially higher among prevalent polypharmacy users at baseline than among those with a new polypharmacy episode (80% vs 24%, p<0.01). Factors associated with chronic polypharmacy included higher age, female gender, living in an institution, chronic multimorbidity, and multi-dose dispensing. CONCLUSION: Polypharmacy is most often chronic, although a substantial share of older adults experience short, recurring episodes of polypharmacy and are thus exposed to its potential harms in a transient rather than persistent manner.Swedish Research Council (2015-03618)Accepte

Discontinuing Chronic Medications Suggested for Deprescribing in Routine Clinical Practice:Nationwide Evidence From Routinely Collected Data in Swedish Older Adults

Background: National estimates of drug discontinuation for deprescribing targets in older adults are limited, partly due to challenges distinguishing planned deprescribing from poor adherence. Focusing on individuals with multidose dispensing (MDD), characterized by high adherence by design, may yield realistic discontinuation rates. Aims: To estimate the rates of discontinuation for chronically used drugs targeted for deprescribing among older adults, and to describe reinitiation among users of MDD and standard dispensing (non-MDD). Methods: In this nationwide cohort study, Swedish adults aged ≥ 75 were identified from national registers. At baseline (1 January 2021), chronic users of seven drug classes were defined. We estimated the 12-month cumulative incidence of discontinuation (defined as no new dispensing during the treatment episode of the prior dispensing plus a 180-day grace period) and the proportion of patients restarting therapy within 180 days after discontinuation. Results: We identified 162 518 chronic users: benzodiazepines (n = 69 511), PPIs (n = 43 973), antidepressants (n = 41 577), statins (n = 36 085), cholinesterase inhibitors (n = 6408), bisphosphonates (n = 5801) and antipsychotics (n = 4380). Discontinuation rates were low (8.3–51.5 per 1000 person-years), and non-MDD users had higher discontinuation and reinitiation rates across all drugs. Conclusion: Discontinuation among Swedish older adults is infrequent. Irregular dispensing is likely misclassified as deprescribing, and MDD users may better reflect true discontinuation in routinely collected data.</p

Is who you ask important? Concordance between survey and registry data on medication use among self- and proxy-respondents in the longitudinal study of aging Danish twins and the Danish 1905-cohort study

This work was supported by the U.S. National Institute of Health (P01AG031719, R01AG026786 and 2P01AG031719), the VELUX Foundation, and the Max Planck Society within the framework of the project “On the edge of societies: New vulnerable populations, emerging challenges for social policies and future demands for social innovation. The experience of the Baltic Sea States (2016–2021).”Background This study investigates the accuracy of the reporting of medication use by proxy- and self-respondents, and it compares the prognostic value of the number of medications from survey and registry data for predicting mortality across self- and proxy-respondents. Methods The study is based on the linkage of the Longitudinal Study of Aging Danish Twins and the Danish 1905–Cohort Study with the Danish National Prescription Registry. We investigated the concordance between survey and registry data, and the prognostic value of medication use when assessed using survey and registry data, to predict mortality for self- and proxy-respondents at intake surveys. Results Among self-respondents, the agreement was moderate (κ = 0.52–0.58) for most therapeutic groups, whereas among proxy-respondents, the agreement was low to moderate (κ = 0.36–0.60). The magnitude of the relative differences was, generally, greater among proxies than among self-respondents. Each additional increase in the total number of medications was associated with 7%–8% mortality increase among self- and 4%–6% mortality increase among proxy-respondents in both the survey and registry data. The predictive value of the total number of medications estimated from either data source was lower among proxies (c-statistic = 0.56–0.58) than among self-respondents (c-statistic = 0.74). Conclusions The concordance between survey and registry data regarding medication use and the predictive value of the number of medications for mortality were lower among proxy- than among self-respondents.Publisher PDFPeer reviewe

Reply to:Peptic ulcers with ChEIs, NSAIDs

See related articles by Montastruc

Cholinesterase inhibitors and non-steroidal anti-inflammatory drugs and the risk of peptic ulcers:A self-controlled study

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.</p

Comparison of sociodemographic factors, healthcare utilisation by general practitioner visits, somatic hospital admissions, and medication use in Norway, Sweden, and Denmark

Purpose: The healthcare systems in Scandinavia inform nationwide registers and the Scandinavian populations are increasingly combined in research. We aimed to compare Norway (NO), Sweden (SE), and Denmark (DK) regarding sociodemographic factors and healthcare. Methods: In this cross-sectional study, we analyzed aggregated data from the nationwide Scandinavian registers. We calculated country-specific statistics on sociodemographic factors and healthcare use (general practitioner visits, admissions to somatic hospitals, and use of medicines). Results: In 2018, population were 5295,619 (NO), 10,120,242 (SE), and 5781,190 (DK). The populations were comparable regarding sex, age, education, and income distribution. Overall, medication use was comparable, while there was more variation in hospital admissions and general practitioner visits. For example, per 1000 inhabitants, 703 (NO), 665 (SE), and 711 (DK) individuals redeemed a prescription, whereas there were 215 (NO), 134 (SE), and 228 (DK) somatic hospital admissions per 1000 inhabitants. General practitioner contacts per 1000 inhabitants were 7082 in DK and 5773 in NO (-data from SE). Conclusion: The Scandinavian countries are comparable regarding aggregate-level sociodemographic factors and medication use. Variations are noted in healthcare utilisation as measured by visits to general practitioners and admissions to hospitals. This variation should be considered when comparing data from the Scandinavian countries.</p

Potentially inappropriate prescribing in polymedicated older adults with atrial fibrillation and multimorbidity: a Swedish national register-based cohort study

IntroductionCurrent research on potentially inappropriate prescribing (PIP) in polymedicated older adults with atrial fibrillation (AF) and multimorbidity is predominantly focused on PIP of oral anticoagulants (OAC). Our study aimed to assess (i) the overall prevalence of PIP in older multimorbid adults with AF, (ii) potential associated factors of PIP, and (iii) the association of PIP with adverse health outcomes in a nationwide sample of Swedish older adults.MethodsSwedish national registries were linked to establish a cohort with a 2-year follow-up of older adults (≥65y) who, on 1 January 2017, had a diagnosis of AF and had at least one comorbidity (n = 203,042). PIP was assessed using the reduced STOPP/START version 2 screening tool. The STOPP criteria identify potentially inappropriate prescribed medications (PIM), while the START criteria identify potential prescribing omissions (PPO). PIP is identified as having at least one PIM and/or PPO. Cox regression analyses were conducted to examine the association between PIP and adverse health outcomes: mortality, hospitalisation, stroke, bleeding, and falls.ResultsPIP was highly prevalent in older adults with AF, with both polypharmacy (69.6%) and excessive polypharmacy (85.9%). In the study population, benzodiazepines (22.9%), hypnotic Z-medications (17.8%) and analgesics (8.7%) were the most frequent PIM. Anticoagulants (34.3%), statins (11.1%), vitamin D and calcium (13.4%) were the most frequent PPO. Demographic factors and polypharmacy were associated with different PIM and PPO categories, with the nature of these associations differing based on the specific type of PIM and PPO. The co-occurrence of PIM and PPO, compared to appropriate prescribing, was associated with an increased risk of adverse health outcomes compared to all appropriately prescribed medications: cardiovascular (CV) (Hazard ratio (HR) [95% confidence interval] = 1.97 [1.88–2.07]) and overall mortality (HR = 2.09 [2.03–2.16]), CV (HR = 1.34 [1.30–1.37]) and overall hospitalisation (HR = 1.48 [1.46–1.51]), stroke (HR = 1.93 [1.78–2.10]), bleeding (HR = 1.10 [1.01–1.21]), and falls (HR = 1.63 [1.56–1.71]).ConclusionThe present study reports a high prevalence of PIP in multimorbid polymedicated older adults with AF. Additionally, a nuanced relationship between prescribing patterns, patient characteristics, and adverse health outcomes was observed. These findings emphasise the importance of implementing tailored interventions to optimise medication management in this patient population

Use of benzodiazepines and benzodiazepine-related drugs in the Nordic countries between 2000 and 2020

Funding Information: MH was supported by a grant from the Mental Health Services in the Region of Southern Denmark during the conduct of this study. HZ was supported by a UNSW Scientia Program Award during the conduct of this study. JWW was supported by a grant from Riksbankens Jubileumsfond during the conduct of this study. Publisher Copyright: © 2022 The Authors. Basic & Clinical Pharmacology & Toxicology published by John Wiley & Sons Ltd on behalf of Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).Use of benzodiazepines (BZ) and related drugs is subject to considerable debate due to problems with dependency and adverse events. We aimed to describe and compare their use across the Nordic countries. Data on the use of clonazepam, BZ-sedatives, BZ-hypnotics, and benzodiazepine-related drugs (BZRD) in adults (≥20 years) were obtained from nationwide registers in Denmark, Finland, Iceland, Norway, and Sweden, 2000–2020. Main measures were therapeutic intensity (TI:DDD/1000 inhabitants [inhab.]/day) and annual prevalence (users/1000 inhab./year). Overall, TI of BZ and related drugs decreased in all Nordic countries from 2004 to 2020. However, there were considerable differences between countries in TI. In 2020, the TI of BZ and related drugs ranged from 17 DDD/1000 inhab./day in Denmark to 93 DDD/1000 inhab./day in Iceland. BZRD accounted for 55–78% of BZ use in 2020, followed by BZ sedatives at 20–44%, BZ-hypnotics at <1–5%, and clonazepam at <1–2%. Annual prevalence of BZ use increased with age in all countries, and the highest annual prevalence was observed among people ≥80 years. Overall, the use of BZ and related drugs has decreased in all Nordic countries from 2004 to 2020, however, with considerable differences in their use between countries. The highest prevalence was observed among the oldest age groups—despite warnings against their use in this population.Peer reviewe