Vol.:(0123456789)
Drugs & Aging (2021) 38:89–91
https://doi.org/10.1007/s40266-020-00818-2 LETTER TO THE EDITOR
Comment on: “Potentially Inappropriate Medications, Drug–Drug
Interactions, and Anticholinergic Burden in Elderly Hospitalized
Patients: Does an Association Exist with Post‑Discharge Health
Outcomes?”
Enrico Brunetti1 · Gianluca Isaia1 · Mario Bo1 Accepted: 5 November 2020 / Published online: 19 November 2020 © Springer Nature Switzerland AG 2020
Dear Editor,
We read with much interest the article recently published in your journal by De Vincentis et al. [1]. This study reported data from the REPOSI registry on 2631 older subjects dis-charged home from internal medicine wards, exploring the association of several pharmacotherapy quality indicators, including potentially inappropriate medications (PIMs) identified by STOPP criteria, with clinical outcomes at 3 months after discharge. Number of prescribed drugs and polytherapy, but neither STOPP PIM prevalence nor any other study indicator, were associated with mortality and readmissions in this sample [1]. These results do not con-cur with those of a previous study in which we investigated the clinical implications of PIMs and potential prescribing omissions (PPOs) according to STOPP/START criteria on mortality and readmissions at 6 months in 611 older patients discharged from acute medical and geriatric wards [2].
Table 1 compares the main characteristics of the subset of 402 home-discharged patients in our study with those of the REPOSI sample. Both studies have included subjects with similar ages and a high prevalence of multimorbidity and polypharmacy. Although all-cause mortality was asso-ciated with neither number of PIMs nor number of drugs at discharge, our study showed a significant independent association between the number of PIMs and unplanned
hospital readmissions in home-discharged patients, after adjustment for relevant prognostic factors derived from a multidimensional geriatric evaluation (aOR 1.38, 95% CI 1.13–1.68). Moreover, the number of drugs at discharge, but not that of PIMs, was independently associated with hospital readmissions in the subsample of 209 patients discharged to middle- or long-term care facilities (aOR 1.27, 95% CI 1.13–1.42) [2].
This discrepancy of results may be ascribed to differ-ent factors. First, the prospective collection of all data in our study, including the identification of PIMs, allowed us to apply the full list of STOPP criteria. De Vincentis and colleagues were able to retrospectively apply a significant proportion of STOPP criteria (63/80, 78.8%), but available data did not allow them to evaluate criteria that were among the top ten PIMs in our sample, such as STOPP criteria A1 (i.e., any drug without an evidence-based indication), D5 (i.e., benzodiazepines for longer than 4 weeks) and F2 [i.e., proton pump inhibitors (PPI) at full therapeutic dosage for longer than 8 weeks], that altogether represented 30.5% of 580 PIMs recorded in the overall sample of our study [2]. This may have led to an under-recognition of PIMs, as sug-gested by their significantly lower prevalence in the REPOSI study (25.6% vs 54%), also considering that inappropriate PPI and benzodiazepine use have been reported in 37% and 9.4% of patients in this registry, respectively [3, 4]. Dif-ferences in the prevalence of specific PIMs among the two study samples might also have contributed to the different recorded impact of PIMs on hospital admissions; however, this remains a speculation since data on the prevalence of single PIMs in the REPOSI sample were not reported. Moreover, even though at first glance the two populations may seem superimposable, the sample we studied seems to include more vulnerable patients: 57.5% of home-discharged subjects in our study was frail according to the Clinical
This comment refers to the article available online at https ://doi. org/10.1007/s4026 6-020-00767 -w.
* Enrico Brunetti enrico.brunetti@unito.it
1 Section of Geriatrics, Department of Medical Sciences,
Università degli Studi di Torino, A.O.U. Città della Salute e della Scienza di Torino, Molinette, Corso Bramante 88, 10126 Turin, Italy
90 E. Brunetti et al.
Frailty Scale, and the level of disability was significantly higher, since 39.6% of patients were completely dependent in at least three out of six activities of daily living (ADLs) [2], while in the REPOSI study 45.6% had a Barthel Index ≤ 90% (i.e., completely dependent in at least 1 ADL or par-tially autonomous in > 1 ADL) [1]. The impact of PIMs could be higher in a population of highly vulnerable older patients living at home, even if the association between num-ber of PIMs and rehospitalization was independent from several geriatric prognostic variables, including functional dependence and cognitive impairment [2]. Lastly, the rela-tively large proportion of patients lost at follow-up in the REPOSI analysis (30.5% vs 8.4%) and the shorter timeframe (3 months vs 6 months) might have hindered the possibility to register a significant proportion of events, thus reducing the study power to identify an association between PIMs and hospitalizations.
Different studies have identified an association of STOPP PIMs with unplanned readmissions in hospital-discharged older patients [5–8], and two of them also with mortality [5, 6]. However, the latter were retrospective and did not assess the prevalence and potential confounding effect of strong prognostic variables in the older population, such as functional status and the presence of frailty or cognitive impairment.
To the best of our knowledge, the study by De Vincentis et al. and our study were the only ones investigating STOPP PIMs that have systematically performed a multidimensional
geriatric assessment in all patients to correct for potential confounding factors, and the discrepancies in outcomes may be largely explained by the difficult retrospective application of STOPP criteria, requiring a thorough evaluation of past medical history and of the present overall patient conditions.
To provide meaningful and clinically reliable informa-tion on the impact of inappropriate prescribing in older patients, future studies need to be specifically designed to allow the application of the full set of STOPP/START criteria at the time of patient enrollment and to include a standardized set of potential confounding variables such as functional dependence, cognitive performance, comorbidity burden and frailty status, stemming from decades of geriatric experience.
Declarations Funding Not applicable.
Conflict of interest All authors declare no competing interests relevant
to the present paper.
Ethics approval Not applicable. Consent to participate Not applicable.
Consent for publication All authors read and consented to the
publica-tion of the final version of the manuscript.
Table 1 Main clinical characteristics and clinical outcomes of home-discharged patients in both studies [1, 2]
ADL activities of daily living, CIRS Cumulative Illness Rating Scale, PIM pontentially inappropriate medications, SBT Short Blessed Test, SPMSQ Short Portable Mental Status Questionnaire, STOPP Screening Tool of Older Persons’ Prescriptions
a Median (interquartile range) b Mean ± standard deviation
c Unpublished data given for ease of comparison [median (interquartile range)]
Clinical variable De Vincentis et al. [1]
All home-discharged patients (n = 2631) Brunetti et al. [2]Home-discharge subset (n = 402)
Age (years) 79 (73–85)a 81.0 ± 7.3b
82 (76–86)c
Female gender 51.4% 44.8%
Functional dependence 45.6%, defined as a Barthel Index ≤ 90/100 39.6%, defined as Katz ADL ≥ 3/6 lost functions Cognitive impairment 42.3%, defined as SBT score ≥ 10/28 19.2%, defined as SPMSQ score ≥ 5/10
CIRS severity index 1.6 (1.4–1.8)a 1.9 ± 0.3b
1.8 (1.7–2.1)c
CIRS comorbidity index 3 (2–4)a 4.7 ± 1.7b
5 (4–6)c
Number of drugs at discharge 8 (5–11)a 7.7 ± 3.2b
8 (5–10)c
Patients with ≥1 STOPP PIM
at discharge 25.6% 54%
Overall mortality 7.3% (at 3 months) 21.4% (at 6 months)
91 Comment on: “PIMs, Drug–Drug Interactions, and Anticholinergic Burden in Elderly Hospitalized Patients”
Availability of data and material Not applicable.
Code availability Not applicable.
Authors’ contributions All authors contributed to the conceptualiza-tion, writing and revision of the manuscript.
References
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