Prescription medication use increased dramatically among older adults between 1988 and 2010. Contemporary older adults on multiple medications have worse health status compared with those on less medications, and appear to be a vulnerable population.

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ObjectiveThe 75% of older adults with multiple chronic conditions are at risk of therapeutic competition (i.e. treatment for one condition may adversely affect a coexisting condition). The objective was to determine the prevalence of potential therapeutic competition in community-living older adults.MethodsCross-sectional descriptive study of a representative sample of 5,815 community-living adults 65 and older in the U.S, enrolled 2007–2009. The 14 most common chronic conditions treated with at least one medication were ascertained from Medicare claims. Medication classes recommended in national disease guidelines for these conditions and used by ≥2% of participants were identified from in-person interviews conducted 2008–2010. Criteria for potential therapeutic competition included: 1), well-acknowledged adverse medication effect; 2) mention in disease guidelines; or 3) report in a systematic review or two studies published since 2000. Outcomes included prevalence of situations of potential therapeutic competition and frequency of use of the medication in individuals with and without the competing condition.ResultsOf 27 medication classes, 15 (55.5%) recommended for one study condition may adversely affect other study conditions. Among 91 possible pairs of study chronic conditions, 25 (27.5%) have at least one potential therapeutic competition. Among participants, 1,313 (22.6%) received at least one medication that may worsen a coexisting condition; 753 (13%) had multiple pairs of such competing conditions. For example, among 846 participants with hypertension and COPD, 16.2% used a nonselective beta-blocker. In only 6 of 37 cases (16.2%) of potential therapeutic competition were those with the competing condition less likely to receive the medication than those without the competing condition.ConclusionsOne fifth of older Americans receive medications that may adversely affect coexisting conditions. Determining clinical outcomes in these situations is a research and clinical priority. Effects on coexisting conditions should be considered when prescribing medications.

In this sample of veterans who had elective surgery with major anesthesia, Mini-Cog score predicted likelihood of postoperative delirium.

Background Patients with dementia constitute an increasing proportion of hospice enrollees, yet little is known about the quality of hospice care for this population. Objectives To quantify differences in quality of care measures between hospice patients with and without dementia. Study Design Cross-sectional analysis of data from the 2007 National Home and Hospice Care Survey Participants 4,711 discharges from hospice care Measurements A primary diagnosis of dementia at discharge was defined by ICD-9 codes: 290.0–290.4x, 294.0, 294.1, 294.8, 331.0–331.2, 331.7, and 331.8. Quality of care measures included enrollment into hospice in the last three days of life, receiving tube feeding, depression, receiving antibiotics, lack of advanced directive or do not resuscitate order, ≥ stage II pressure ulcers, emergent care, lack of continuity of residence and a report of pain at last assessment. Results 450 (9.5%) discharges had a primary diagnosis of dementia. In multivariable analysis, patients with dementia were more likely to receive tube feeding [OR 2.6 (95% CI: 1.4, 4.5)] and to have greater continuity of residence [OR 1.8 (95% CI: 1.1, 3.0)] compared to other hospice patients. They were less likely to have a report of pain at last assessment [OR 0.6 (95% CI: 0.3, 0.9)]. Conclusions The majority of quality of care measures examined in this study did not differ between hospice patients with and without dementia. Use of tube feeding in hospice care and methods of pain assessment and treatment in patients with dementia should be considered as potential quality of care measures.

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ImportanceRandomized trials of anti-hypertensive treatment demonstrating reduced risk of cardiovascular events in older adults included participants with less comorbidity than clinical populations. Whether these results generalize to all older adults, most of whom have multiple chronic conditions, is uncertain.ObjectiveTo determine the association between anti-hypertensive medications and CV events and mortality in a nationally representative population of older adults.DesignCompeting risk analysis with propensity score adjustment and matching in the Medicare Current Beneficiary Survey cohort over three-year follow-up through 2010.Participants and Setting4,961 community-living participants with hypertension.ExposureAnti-hypertensive medication intensity, based on standardized daily dose for each anti-hypertensive medication class participants used.Main Outcomes and MeasuresCardiovascular events (myocardial infarction, unstable angina, cardiac revascularization, stroke, and hospitalizations for heart failure) and mortality.ResultsOf 4,961 participants, 14.1% received no anti-hypertensives; 54.6% received moderate, and 31.3% received high, anti-hypertensive intensity. During follow-up, 1,247 participants (25.1%) experienced cardiovascular events; 837 participants (16.9%) died. Of deaths, 430 (51.4%) occurred in participants who experienced cardiovascular events during follow-up. In the propensity score adjusted cohort, after adjusting for propensity score and other covariates, neither moderate (adjusted hazard ratio, 1.08 [95% CI, 0.89–1.32]) nor high (1.16 [0.94–1.43]) anti-hypertensive intensity was associated with experiencing cardiovascular events. The hazard ratio for death among all participants was 0.79 [0.65–0.97] in the moderate, and 0.72 [0.58–0.91] in the high intensity groups compared with those receiving no anti-hypertensives. Among participants who experienced cardiovascular events, the hazard ratio for death was 0.65 [0.48–0.87] and 0.58 [0.42–0.80] in the moderate and high intensity groups, respectively. Results were similar in the propensity score-matched subcohort.Conclusions and RelevanceIn this nationally representative cohort of older adults, anti-hypertensive treatment was associated with reduced mortality but not cardiovascular events. Whether RCT results generalize to older adults with multiple chronic conditions remains uncertain.

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