Methodological Issues in Pharmacotherapy Research in Older Adults

Orwig, Denise; Rickles, Nathaniel M.; Martin, Linda G.

doi:10.1016/j.amjopharm.2011.04.008

Cited by 13 publications

(18 citation statements)

References 72 publications

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“…Whilst the greatest attrition in our study occurred between baseline and phase 2, overall retention rates were good and, although showing some associations, statistical analysis detected no strong predictors of attrition due to withdrawal, suggesting minimal attrition bias. While our findings accord with the fact that women live longer than men [33] but with greater levels of disability [34] – [37] , they conflict with those reporting that post-inclusion attrition rates due to withdrawal increase with length of follow-up [13] , [38] . A systematic review found that only increasing age and cognitive impairment were significantly associated with greater attrition due to withdrawal in longitudinal studies of ageing [28] .…”

Section: Discussioncontrasting

confidence: 49%

Improving Retention of Very Old Participants in Longitudinal Research: Experiences from the Newcastle 85+ Study

et al. 2014

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BackgroundPeople aged 85 and over are often excluded from research on the grounds of being difficult to recruit and problematic to retain. The Newcastle 85+ study successfully recruited a cohort of 854 85-year-olds to detailed health assessment at baseline and followed them up over 3 phases spanning 5 years. This paper describes the effectiveness of its retention strategies.MethodsPrimary retention strategies involved meticulous management of contact information and active maintenance of contact with participants between research visits and between phases of the study. For statistical analysis, data on post-inclusion attrition over the 3 follow-up phases was separated into ‘death’ and ‘withdrawal’ categories, with sub-categories ‘health’ and ‘non-health’ reasons created for ‘withdrawal’. Multinomial logistic regression was used to determine if particular socio-demographic and health characteristics were associated with post-inclusion attrition due to withdrawal at each of the 3 phase-to-phase transition points.ResultsFor both sexes, at successive follow-up phases there was a decrease in attrition due to withdrawal and an increase due to death. Withdrawal was most prevalent between baseline and phase 2. Across the 5 years of the study total post-inclusion (post-baseline) attrition due to death accounted for a 40% (344/854) loss to cohort and total post-inclusion attrition due to withdraw a 19% (166/854) loss to cohort, with health reasons for withdrawal becoming more dominant over time. Adjusting for sex, parsimonious modelling showed only occupational class (National Statistics Socio-economic Classification) to be associated with withdrawal and only between baseline and phase 2 (routine/manual compared to managerial (OR 3.41; 95% CI [1.23 to 9.44]).ConclusionFollowing successful recruitment, we retained a high proportion of participants from a very old age group over 5 years of longitudinal research. No strong predictors of post-inclusion attrition due to withdrawal were found, suggesting the general effectiveness of our retention strategies.

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Section: Discussioncontrasting

confidence: 49%

Improving Retention of Very Old Participants in Longitudinal Research: Experiences from the Newcastle 85+ Study

et al. 2014

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“…Appropriate prescribing involves an understanding of the effect of ageing on physiology and pharmacokinetics, a knowledge of pharmacology, the ability to balance risks versus benefits, and a willingness to listen to patient and caregiver concerns . Practitioners experience an ongoing challenge in finding age‐ and disease‐appropriate evidence as many clinical trials continue to exclude the very frail, or older patients with multiple morbidities . Moreover, life expectancy and cost efficiency must also be considered in best prescribing practices.…”

Section: What Is Known and Objectivementioning

confidence: 99%

“…1,2 Practitioners experience an ongoing challenge in finding age-and disease-appropriate evidence as many clinical trials continue to exclude the very frail, or older patients with multiple morbidities. 3 Moreover, life expectancy and cost efficiency must also be considered in best prescribing practices.…”

Section: What Is Known and Objectivementioning

confidence: 99%

Effectiveness of the STOPP/START (Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria: systematic review and meta-analysis of randomized controlled studies

et al. 2016

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SUMMARYWhat is known and objective: STOPP/START are explicit screening tools that identify potentially inappropriate prescribing in older adults. Our objective was to update our 2013 systematic review that showed limited evidence of impact, using new evidence from randomized controlled trials (RCTs) assessing clinical, humanistic and economic outcomes in older adults. Methods: We performed a search of PubMed, EMBASE, CINAHL, Web of Science and grey literature for RCTs published in English since the previous review through June 2014. The Cochrane Risk of Bias Tool was used. We performed a meta-analysis on the effect of STOPP on potentially inappropriate medication (PIM) rates and a narrative synthesis on other outcomes. Results and discussion: Four RCTs (n = 1925 adults) from four countries were included, reporting both acute (n = 2) and longterm care (n = 2) patients. Studies differed in implementation. Two studies were judged to have low risk, and two to have moderate-to-high risk of bias in key domains. Meta-analysis found that the STOPP criteria reduced PIM rates in all four studies, but study heterogeneity (I 2 = 86Á7%) prevented the calculation of a meaningful statistical summary. We found evidence that use of the criteria reduces falls, delirium episodes, hospital length-of-stay, care visits (primary and emergency) and medication costs, but no evidence of improvements in quality of life or mortality. What is new and conclusion: STOPP/START may be effective in improving prescribing quality, clinical, humanistic and economic outcomes. Additional research investigating these tools is needed, especially in frail elderly and community-living patients receiving primary care. WHAT IS KNOWN AND OBJECTIVEMedication use in older adults occurs in a complex environment. Appropriate prescribing involves an understanding of the effect of ageing on physiology and pharmacokinetics, a knowledge of pharmacology, the ability to balance risks versus benefits, and a willingness to listen to patient and caregiver concerns.1,2 Practitioners experience an ongoing challenge in finding age-and disease-appropriate evidence as many clinical trials continue to exclude the very frail, or older patients with multiple morbidities. Moreover, life expectancy and cost efficiency must also be considered in best prescribing practices.Potentially inappropriate prescribing (PIP) is a term that encompasses the prescribing of potentially inappropriate medication (PIM) where risks and costs outweigh potential benefits, as well as potential prescribing omission (PPO), where clinically beneficial medications may not be prescribed for a number of reasons. 1,4 There is agreement that PIP is prevalent in older patients. 1,5 Studies that determine the incidence or prevalence of PIP in older adults report a range of rates dependent on the healthcare setting and the characteristics of population studied. The rates reported also vary depending on the instrument used to measure PIP. A recent study in Sweden used five explicit screening tools and found 38% o...

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“…The evidence on which clinical guidelines are based usually stems from randomized clinical trials or meta-analyses, which are often biased by the exclusion or under-representation of elderly people, especially those affected by multimorbidity and receiving polypharmacy [ 24 , 80 – 84 ]. A recent analysis of patient enrollment in clinical trials for cancer drugs found only 20% and 9%, respectively, of patients older than 70 and 75 years, compared with 46% and 31% for the whole cancer population in the USA [ 82 ].…”

Section: Limitations Of Guidelines In Elderly Peoplementioning

confidence: 99%

Multiple Diseases and Polypharmacy in the Elderly: Challenges for the Internist of the Third Millennium

2011

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The pattern of patients admitted to internal medicine wards has dramatically changed in the last 20–30 years. Elderly people are now the most rapidly growing proportion of the patient population in the majority of Western countries, and aging seldom comes alone, often being accompanied by chronic diseases, comorbidity, disability, frailty, and social isolation. Multiple diseases and multimorbidity inevitably lead to the use of multiple drugs, a condition known as polypharmacy. Over the last 20–30 years, problems related to aging, multimorbidity, and polypharmacy have become a prominent issue in global healthcare. This review discusses how internists might tackle these new challenges of the aging population. They are called to play a primary role in promoting a new, integrated, and comprehensive approach to the care of elderly people, which should incorporate age-related issues into routine clinical practice and decisions. The development of new approaches in the frame of undergraduate and postgraduate training and of clinical research is essential to improve and implement suitable strategies meant to evaluate and manage frail elderly patients with chronic diseases, comorbidity, and polypharmacy.Journal of Comorbidity 2011;1:28–44

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Methodological Issues in Pharmacotherapy Research in Older Adults

Cited by 13 publications

References 72 publications

Improving Retention of Very Old Participants in Longitudinal Research: Experiences from the Newcastle 85+ Study

Improving Retention of Very Old Participants in Longitudinal Research: Experiences from the Newcastle 85+ Study

Effectiveness of the STOPP/START (Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria: systematic review and meta-analysis of randomized controlled studies

Multiple Diseases and Polypharmacy in the Elderly: Challenges for the Internist of the Third Millennium

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