older adults

Evaluating and Treating Alcohol Use in Older Adult Patients

Nathan Hinkle — Tue, 04 Aug 2026 20:36:31 +0000

Date Added:

August 4, 2026

Journal/Publication:

Canadian Family Physician/Le Medecin De Famille Canadien

Publisher:

College of Family Physicians of Canada

Publication Date:

July 29, 2026

Issue:

7-8

Volume:

Pages:

466-468

URL:

Evaluating and treating alcohol use in older adult patients

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.46747/cfp.720708466

Keywords

alcohol use

older adults

cardiovascular disease

MeSH

alcohol drinking

frailty

aged

RPR Commentary: A review of the recognition, assessment, and treatment of older patients who regularly drink alcohol-containing beverages. James W. Mold, MD, MPH

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Clinical question
How do I evaluate and treat alcohol use in older
adult patients?
Bottom line
Although older adults generally drink less alcohol than
their younger counterparts,1 the consequences of use
are more severe. Older adults are more susceptible to
alcohol-related toxicity due to physiologic changes.2
The health impacts of heavy alcohol intake include
increased risks of cardiovascular disease, stroke, liver
disease, cancer, and mortality.3 Acute and chronic
alcohol use contributes to geriatric syndromes, such as
cognitive impairment, falls, frailty, and malnutrition.4

Author/s:

Frank, Chris, Molnar, Rummell, Sonja, Chan, Peter

Footwear Characteristics and Their Impact on Gait and Balance in Older Adults: A Systematic Review of Recent Evidence

Nathan Hinkle — Tue, 21 Jul 2026 21:39:21 +0000

Date Added:

July 21, 2026

Journal/Publication:

Journal of the American Geriatrics Society

Publisher:

American Geriatrics Society

Publication Date:

July 17, 2026

URL:

Footwear Characteristics and Their Impact on Gait and Balance in Older Adults: A Systematic Review of Recent Evidence

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

https://doi.org/10.1111/jgs.70577

Keywords

MeSH

Accidental Falls* / prevention & control

RPR Commentary: A review of modifications in footwear design shoen to improve gait and balance in seniors. James W. Mold, MD, MPH

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Background
Improper footwear has been identified as a modifiable risk factor for falls in older adults. Studies suggest that certain footwear characteristics can impair gait and balance, thereby increasing the risk of falls. However, the impact of footwear on gait and balance control may vary across research protocols. A systematic review focusing on these relationships is currently unavailable to date. This study aims to investigate the impact of footwear on gait and balance control in older adults, as well as the research protocols employed and the study outcomes.

Method
A systematic review was conducted using PubMed, IEEE Xplore, Scopus, Web of Science, and Clinical Trials to identify relevant studies published between 2017 and 2024. Keywords were systematically searched, and data were manually extracted. Thirteen studies were included. The review synthesized findings on the influence of various footwear designs on gait and balance control in older adults.

Result
Footwear featuring a minimal outsole, a textured insole design, and a high collar design was generally associated with improved balance outcomes. The evidence for toe-beveled footwear designs was mixed. Studies incorporated both walking and balance assessments, with some including perception-based questionnaires. A combination of walking, balance, and perceptual assessments provides a more comprehensive understanding of how footwear affects balance in older adults.

Conclusion
Among the included studies, featuring a minimal outsole, a textured insole design, and a high collar design showed consistency to benefit older adults that provides textured feedback while offering foot protection, which may enhance balance control. However, some studies also implied that certain designs may have potential negative effects, including toe-beveled, minimal outsole, less-fixation, and barefoot condition. The lack of comprehensive descriptions of experimental footwear affects scientific transparency and reproducibility.

Author/s:

Chi-Hsien Chen, Jinfeng Li, Yoshiro Okubo

Evaluating Inflammatory Joint Pain in Older Adults-Practical Diagnostic Clues for Primary Care Clinicians

Nathan Hinkle — Wed, 17 Jun 2026 00:59:54 +0000

Date Added:

June 16, 2026

Journal/Publication:

JAMA Intern Med

Publisher:

The American Medical Association

Publication Date:

June 8, 2026

URL:

Evaluating Inflammatory Joint Pain in Older Adults-Practical Diagnostic Clues for Primary Care Clinicians

Type:

Meta-analyses, Reviews, and Guidelines

CME Credits:

Format:

Article

DOI (1):

doi: 10.1001/jamainternmed.2026.2032

Keywords

Arthritis, Rheumatoid

MeSH

RPR Commentary: A review of the evaluation of older patients with joint inflammation. James W. Mold, MD, MPH

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Arthritis is a leading cause of pain and disability that affects nearly one-third of older US adults (age ≥65 years). While osteoarthritis (OA) predominates, many have inflammatory arthritis (IA), including rheumatoid arthritis (RA), spondyloarthritis, and crystal arthropathies.1 Recognition of IA is frequently delayed for longer than a year in older adults due to atypical and overlapping presentations.2 Untreated IA can lead to irreversible damage, functional decline, and prolonged glucocorticoid exposure. Joint pain is often initially evaluated by primary care clinicians; therefore, timely recognition and early management are essential. This article highlights unique aspects of IA in older adults and offers practical guidance.

Author/s:

Jiha Lee, Justin B Levinson, Una E Makris

Evidence-Based Footwear Recommendations for Older Adults: Enhancing Mobility, Comfort, and Fall Prevention

Megan George — Mon, 23 Feb 2026 17:28:17 +0000

Date Added:

February 23, 2026

Journal/Publication:

Journal of the American Geriatric Society

Publication Date:

September 30, 2025

URL:

Evidence-Based Footwear Recommendations for Older Adults: Enhancing Mobility, Comfort, and Fall Prevention

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1111/jgs.70111

Keywords

PMID (1):

41024675

MeSH

Accidental Falls* / prevention & control

Evidence-Based Medicine

A concise summary of shoe characteristics that can benefit older people in various ways. James W. Mold, MD, MPH

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Background: Older adults often struggle to find footwear suitable for their clinical needs, thus affecting mobility, safety, and quality of life. Proper footwear is important due to fall risk, balance impairments, knee osteoarthritis (OA), hallux rigidus, plantar fasciitis, diabetic neuropathy, and limb length discrepancies (LLDs). Barriers such as inadequate clinical guidance and limited patient understanding persist. This paper provides updated, evidence-based recommendations for these challenges.

Methods: A topic review was conducted to evaluate shoe wear characteristics that address geriatric needs. Recommendations were synthesized from more than 45 years of clinical experience in physical therapy and categorized by clinical conditions. Evidence identified effective shoe features, including sole stiffness, tread patterns, heel elevation, and orthotic modifications to improve function, reduce pain, and reduce fall risk.

Results: Balance and fall risk: Shoes with wide soles, medium-firm materials, low heels, and high collars improved stability and reduced postural sway. Cupped, rigid insoles enhanced dynamic control, while treaded rubber outsoles minimized slipping. Knee OA: Flexible shoes with laterally wedged insoles and minimal heel lift reduced medial knee loads and pain. Supportive shoes and medially wedged insoles decreased lateral knee loads and pain. Hallux rigidus/bunions: Rocker-bottom shoes and stiffer soles accommodate deformities, improving function and comfort. Plantar fasciitis: Orthoses, supportive therapies, and stretching regimens were efficacious. Diabetic neuropathy: Rigid rocker soles and custom insoles reduced plantar pressure and ulcer recurrence. LLDs: Gradual shoe lift introduction alleviated low back pain. General recommendations: Properly fitted, comfortable shoes with moderately firm insoles, slip-resistant outsoles, and secure fastening mechanisms improve safety and function.

Conclusions: Footwear significantly impacts the mobility, safety, and well-being of older adults. Tailored recommendations enhance pain management, independence, and fall prevention. Providers should involve patients in decisions and counsel against the use of slippers or excessively elevated heels.

Keywords: fall prevention; older adults; orthoses; pain; shoes.

Author/s:

C Ray Cheever, Hyoungjun Sim, Mohamed Y. Ahmidouch, Jaewon Moon, Anissa Powell, Rayad B. Shams, Matthew Wang, Madison Hunter, Samantha Kodikara, Lindsay A. Wilson, Michael T. Gross

Clinician's Guide to Assessing and Counseling Older Drivers, 4th Edition

Erin Blanchette — Mon, 09 Dec 2024 15:14:17 +0000

Date Added:

December 9, 2024

Publisher:

American Geriatrics Society

Pages:

1-282

URL:

Clinician's Guide to Assessing and Counseling Older Drivers, 4th Edition

Type:

Clinical Decision Aids

Format:

Web Page

Keywords

MeSH

Guidance for how to assess a person's capacity to drive safely. James W. Mold, MD, MPH

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The Clinician’s Guide to Assessing and Counseling Older Drivers, 4th Edition is published by the American Geriatrics Society (AGS) as a service to healthcare providers involved in the care of older adults. This 4th edition is an update of the 3rd edition to the current state of the literature, with a continued focus on the interprofessional nature of the team caring for an older adult driver. This edition is the result of a cooperative agreement between AGS and the U.S. Department of Transportation’s National Highway Traffic Safety Administration (NHTSA).

The Clinician’s Guide is available in two formats, a digital text accessed through your browser and a downloadable PDF.

Surveillance Colonoscopy Findings in Older Adults With a History of Colorectal Adenomas

Alex Haga — Sun, 07 Apr 2024 19:44:16 +0000

Date Added:

April 7, 2024

Journal/Publication:

JAMA Network Open

Publisher:

JAMA

Publication Date:

April 1, 2024

Issue:

Volume:

URL:

Surveillance Colonoscopy Findings in Older Adults With a History of Colorectal Adenomas

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2024.4611

Keywords

Adenoma

Colonoscopy

older adults

PMID (1):

38564216

MeSH

Adenoma* / diagnosis

Adenoma* / epidemiology

Colorectal Neoplasms* / diagnosis

Colorectal Neoplasms* / epidemiology

Cross-Sectional Studies

Humans

male

This study suggests that surveillance colonoscopies for patients over 75 with a prior adenomatous polyp are unlikely to improve life expectancy especially if pretest life expectancy is less than 10 years.

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Importance
Postpolypectomy surveillance is a common colonoscopy indication in older adults; however, guidelines provide little direction on when to stop surveillance in this population.

Objective
To estimate surveillance colonoscopy yields in older adults.

Design, Setting, and Participants
This population-based cross-sectional study included individuals 70 to 85 years of age who received surveillance colonoscopy at a large, community-based US health care system between January 1, 2017, and December 31, 2019; had an adenoma detected 12 or more months previously; and had at least 1 year of health plan enrollment before surveillance. Individuals were excluded due to prior colorectal cancer (CRC), hereditary CRC syndrome, inflammatory bowel disease, or prior colectomy or if the surveillance colonoscopy had an inadequate bowel preparation or was incomplete. Data were analyzed from September 1, 2022, to February 22, 2024.

Exposures
Age (70-74, 75-79, or 80-85 years) at surveillance colonoscopy and prior adenoma finding (ie, advanced adenoma vs nonadvanced adenoma).

Main Outcomes and Measures
The main outcomes were yields of CRC, advanced adenoma, and advanced neoplasia overall (all ages) by age group and by both age group and prior adenoma finding. Multivariable logistic regression was used to identify factors associated with advanced neoplasia detection at surveillance.

Results
Of 9740 surveillance colonoscopies among 9601 patients, 5895 (60.5%) were in men, and 5738 (58.9%), 3225 (33.1%), and 777 (8.0%) were performed in those aged 70-74, 75-79, and 80-85 years, respectively. Overall, CRC yields were found in 28 procedures (0.3%), advanced adenoma in 1141 (11.7%), and advanced neoplasia in 1169 (12.0%); yields did not differ significantly across age groups. Overall, CRC yields were higher for colonoscopies among patients with a prior advanced adenoma vs nonadvanced adenoma (12 of 2305 [0.5%] vs 16 of 7435 [0.2%]; P = .02), and the same was observed for advanced neoplasia (380 of 2305 [16.5%] vs 789 of 7435 [10.6%]; P < .001). Factors associated with advanced neoplasia at surveillance were prior advanced adenoma (adjusted odds ratio [AOR], 1.65; 95% CI, 1.44-1.88), body mass index of 30 or greater vs less than 25 (AOR, 1.21; 95% CI, 1.03-1.44), and having ever smoked tobacco (AOR, 1.14; 95% CI, 1.01-1.30). Asian or Pacific Islander race was inversely associated with advanced neoplasia (AOR, 0.81; 95% CI, 0.67-0.99).

Conclusions and Relevance
In this cross-sectional study of surveillance colonoscopy yield in older adults, CRC detection was rare regardless of prior adenoma finding, whereas the advanced neoplasia yield was 12.0% overall. Yields were higher among those with a prior advanced adenoma than among those with prior nonadvanced adenoma and did not increase significantly with age. These findings can help inform whether to continue surveillance colonoscopy in older adults.

Author/s:

Lee, JK, Roy, A., Jensen, C.D., Chan, J.T., Zhao, W.K.

Effects of dance therapy on cognitive and mental health in adults aged 55 years and older with mild cognitive impairment: a systematic review and meta-analysis

Erin Blanchette — Mon, 13 Nov 2023 16:54:42 +0000

Date Added:

November 13, 2023

Journal/Publication:

BMC Geriatrics

Publisher:

BioMed Central

Publication Date:

October 26, 2023

Issue:

Volume:

695

URL:

Effects of dance therapy on cognitive and mental health in adults aged 55 years and older with mild cognitive impairment: a systematic review and meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1186/s12877-023-04406-y

Keywords

Dance therapy

Mild cognitive impairment

older adults

Cognitive

mental health

PMID (1):

37880590

MeSH

aged

Cognition

Cognitive Dysfunction* / therapy

dementia

dance therapy

Dance therapy improves cognitive function in people with mild cognitive impairment. Makes sense (Music plus physical activity). James W. Mold, MD, MPH

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Background: Individuals with mild cognitive impairment are at high risk of developing dementia. Dance therapy has promising applications in delaying cognitive decline. However, the effectiveness of dance therapy for older adults with mild cognitive impairment is unclear. The objective of this review was to evaluate the effectiveness of dance therapy on global cognitive function, specific cognitive subdomains, quality of life, and mental health in older adults with mild cognitive impairment to enrich health management strategies for dementia.

Methods: Electronic databases and grey literature were searched from inception up to September 23, 2023. The language was limited to English and Chinese. Relevant studies were screened and assessed for risk of bias. A meta-analysis and subgroup analyses stratified by measurement instrument, dance type, intervention duration, and frequency were conducted using the STATA 16.0 software. This review was conducted in accordance with the PRISMA guidelines.

Results: Ten studies involving 984 participants aged 55 years and over who met the eligibility criteria were included. Dance therapy significantly improved global cognitive function, memory, executive function, attention, language, and mental health (i.e., depression and neuropsychiatric symptoms). However, the effects of dance therapy on processing speed, visuospatial ability, and quality of life in older adults with mild cognitive impairment remain inconclusive. Moreover, dance interventions of longer duration (> 3 months) improved global cognition more than shorter interventions.

Conclusion: This review reported that dance therapy was effective in improving global cognitive function, memory, executive function, attention, language, and mental health (i.e., depression and neuropsychiatric symptoms). Hence, it may be an effective non-pharmacological complementary treatment for older adults with mild cognitive impairment.

Author/s:

Chen-shan Huang, Yuan-jiao Yan, Yu-ting Luo, Rong Lin, Hong Li

Catheter ablation and lower risk of incident dementia and mortality in older adults with atrial fibrillation

Rowan Hutchins — Mon, 02 Oct 2023 05:00:00 +0000

Date Added:

October 2, 2023

Journal/Publication:

Journal of the American Geriatrics Society

Publisher:

American Geriatrics Society

Publication Date:

August 23, 2023

URL:

Catheter ablation and lower risk of incident dementia and mortality in older adults with atrial fibrillation

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1111/jgs.18538

Keywords

PMID (1):

37609682

MeSH

Urinary Catheters

Atrial Fibrillation* / diagnosis

RPR Commentary: It looks like catheter ablation is becoming the preferred treatment for many patients with atrial fibrillation for a variety of reasons including dementia prevention. James W. Mold, MD, MPH

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Background: Atrial fibrillation (AF) has consistently been associated with a higher risk of incident dementia. Observational evidence has suggested catheter ablation may be associated with a lower risk of dementia in patients with AF, but further research is needed. The objectives of this study were to use a global health research network to examine associations between catheter ablation, incident dementia and mortality in older adults with AF, and amongst subgroups by age, sex, co-morbidity status, and oral anticoagulant use.

Methods: The research network primarily included healthcare organizations in the United States. This network was searched on 28th September 2022 for patients aged ≥65 years with a diagnosis of AF received at least 5 years prior to the search date. Cox proportional hazard models were run on propensity-score matched cohorts.

Results: After propensity score matching, 20,746 participants (mean age 68 years; 59% male) were included in each cohort with and without catheter ablation. The cohorts were well balanced for age, sex, ethnicity, co-morbidities, and cardiovascular medications received. The risk of dementia was significantly lower in the catheter ablation cohort (Hazard Ratio 0.52, 95% confidence interval: 0.45-0.61). The catheter ablation cohort also had a lower risk of all-cause mortality (Hazard Ratio 0.58, 95% confidence interval: 0.55-0.61). These associations remained in subgroup analyses in individuals aged 65-79 years, ≥80 years, males, females, participants who received OACs during follow-up, participants with paroxysmal and non-paroxysmal AF, and participants with and without hypertension, diabetes mellitus, ischemic stroke, chronic kidney disease and heart failure, including heart failure with preserved ejection fraction and heart failure with reduced ejection fraction.

Conclusion: The observed lower risk of dementia and mortality with catheter ablation could be an important consideration when determining appropriate patient-centered rhythm control strategies for patients with AF. Further studies including data on the success of ablation are required.

Author/s:

Harrison, Stephanie L., Buckley, Benjamin J.R.

Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial

Devin Evans — Wed, 24 Feb 2021 06:00:00 +0000

Date Added:

February 24, 2021

Journal/Publication:

Journal of the American Medical Association Internal Medicine

Publication Date:

February 22, 2021

URL:

Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamainternmed.2020.9049

Keywords

Telephone Cognitive Behavioral Therapy

PMID (1):

33616613

MeSH

aged

sleep initiation and maintenance disorders

Sleep Hygiene

osteoarthritis

Cognitive Behavioral Therapy

Telephone

Cognitive behavioral therapy is apparently the most effective way to help people sleep better, even if provided virtually. James W. Mold, MD, MPH

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Importance: Scalable delivery models of cognitive behavioral therapy for insomnia (CBT-I), an effective treatment, are needed for widespread implementation, particularly in rural and underserved populations lacking ready access to insomnia treatment.

Objective: To evaluate the effectiveness of telephone CBT-I vs education-only control (EOC) in older adults with moderate to severe osteoarthritis pain.

Design, setting, and participants: This is a randomized clinical trial of 327 participants 60 years and older who were recruited statewide through Kaiser Permanente Washington from September 2016 to December 2018. Participants were double screened 3 weeks apart for moderate to severe insomnia and osteoarthritis (OA) pain symptoms. Blinded assessments were conducted at baseline, after 2 months posttreatment, and at 12-month follow-up.

Interventions: Six 20- to 30-minute telephone sessions provided over 8 weeks. Participants submitted daily diaries and received group-specific educational materials. The CBT-I instruction included sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and homework. The EOC group received information about sleep and OA.

Main outcomes and measures: The primary outcome was score on the Insomnia Severity Index (ISI) at 2 months posttreatment and 12-month follow-up. Secondary outcomes included pain (score on the Brief Pain Inventory-short form), depression (score on the 8-item Patient Health Questionnaire), and fatigue (score on the Flinders Fatigue Scale).

Results: Of the 327 participants, the mean (SD) age was 70.2 (6.8) years, and 244 (74.6%) were women. In the 282 participants with follow-up ISI data, the total 2-month posttreatment ISI scores decreased 8.1 points in the CBT-I group and 4.8 points in the EOC group, an adjusted mean between-group difference of -3.5 points (95% CI, -4.4 to -2.6 points; P < .001). Results were sustained at 12-month follow-up (adjusted mean difference, -3.0 points; 95% CI, -4.1 to -2.0 points; P < .001). At 12-month follow-up, 67 of 119 (56.3%) participants receiving CBT-I remained in remission (ISI score, ≤7) compared with 33 of 128 (25.8%) participants receiving EOC. Fatigue was also significantly reduced in the CBT-I group compared with the EOC group at 2 months posttreatment (mean between-group difference, -2.0 points; 95% CI, -3.1 to -0.9 points; P = <.001) and 12-month follow-up (mean between-group difference, -1.8 points; 95% CI, -3.1 to -0.6 points; P = .003). Posttreatment significant differences were observed for pain, but these differences were not sustained at 12-month follow-up.

Conclusions and relevance: In this randomized clinical trial, telephone CBT-I was effective in improving sleep, fatigue, and, to a lesser degree, pain among older adults with comorbid insomnia and OA pain in a large statewide health plan. Results support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment.

Author/s:

McCurry, Susan M., Zhu, Weiwei, Von Korff, Michael, Wellman, Robert, Morin, Charles M., Thakral, Manu, Yeung, Kai, Vitiello, Michael V.

Polypharmacy Management in Older Patients

Devin Evans — Thu, 14 Jan 2021 06:00:00 +0000

Date Added:

January 21, 2021

Journal/Publication:

Mayo Clinic Proceedings

Publication Date:

January 5, 2021

Issue:

Volume:

Pages:

242-256

URL:

Polypharmacy Management in Older Patients

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.mayocp.2020.06.012

Keywords

PMID (1):

33413822

MeSH

A nice summary of the hazards, prevention, and management of polypharmacy in the elderly. James W. Mold, MD, MPH

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Medications to treat disease and extend life in our patients often amass in quantities, resulting in what has been termed "polypharmacy." This imprecise label usually describes the accumulation of 5, and often more, medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. Polypharmacy is associated with resulting increased hospitalizations and higher costs of care for individuals and health care systems. To reduce polypharmacy, we delineate a systematic, consultative approach to identify highest-risk medications and drug-therapy problems. We address strategic reductions (deprescribing) of medications in palliative care, long-term care, and ambulatory older adults. Best practices for reducing opioids, benzodiazepines, and other high-risk medications include education about risk and agreement by patients and their families, advocates, and care teams. Addressing deprescribing should be within the framework of patients' health status as their care and goals transition from longevity to a plan of maintaining alertness, comfort, and satisfaction of quality of life. A team approach to address polypharmacy and avoidance of high-risk therapy is optimal within long-term care. Patients with terminal illnesses or those moving toward a comfort-care emphasis benefit from medication adjustments that are recognized beneficially within each patient's care goals. In caring for older adults, the acknowledgement that complicated regimens and high-risk medications requires a care plan to reduce or prevent medication-related problems and costs that are associated with polypharmacy.

Author/s:

Hoel, Robert W., Giddings-Connolly, Ryan M., Takahashi, Paul Y.

Prevention, Diagnosis, and Management of Opioids, Opioid Misuse and Opioid Use Disorder in Older Adults

Brian Desmarais — Sat, 07 Nov 2020 21:37:46 +0000

Date Added:

January 21, 2021

Journal/Publication:

U.S. Department of Health and Human Services

Publication Date:

November 3, 2020

URL:

Prevention, Diagnosis, and Management of Opioids, Opioid Misuse and Opioid Use Disorder in Older Adults

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

MeSH

analgesics, non-narcotic

opioid-related disorders

Prescription Drug Monitoring Programs

analgesics, opioid

An AHRQ evidence review on the prevention, diagnosis, and management of opioid misuse. James W. Mold, MD, MPH

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Structured Abstract

Background. Opioid-related harms are increasing among older adults. Until we better understand the factors contributing to this trend, we will be unable to design and implement effective interventions to optimally manage opioid use and its potential harms among older adults. Although considerable research has been done in younger or mixed-age populations, the degree to which it is directly applicable to older adults is uncertain.

Objectives. To provide a framework for understanding how to reduce adverse outcomes of opioid use among older adults, and to describe the evidence available for different factors associated with and interventions to reduce adverse outcomes related to opioid use in this population.

Approach. With input from a diverse panel of content experts and other stakeholders, we developed a conceptual framework and evidence map to characterize empirical studies of factors associated with opioid-related outcomes and interventions to reduce opioid-related harms in older adults. We identified relevant literature among older adults (age ≥60 years) for an evidence map by systematically searching PubMed, PsycINFO, and CINAHL for studies published in English between 2000 and May 6, 2020.

Findings. We identified 5,933 citations, from which we identified 41 studies with multivariable models of factors associated with opioid-related outcomes and 16 studies of interventions in older adults. More than half (22/41) of the multivariable analysis studies evaluated factors associated with long-term opioid use (which, though not a harm per se, may increase the risk of harms if not appropriately managed). Prior or early postoperative opioid use, or greater amounts of prescribed opioids (high number of opioid prescriptions or higher opioid dose), were consistently (100% agreement) and strongly (measure of association ≥2.0) associated with long-term opioid use. Back pain, depression, concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs), and fibromyalgia also had consistent, but weaker, associations with long-term opioid use. Several factors were mostly associated (>75% agreement) with long-term opioid use, including benzodiazepine use, comorbidity scores, (generally undefined) substance misuse, tobacco use, and low income. However, studies were mostly consistent that alcohol abuse and healthcare utilization were not associated with long-term opioid use. Gender, age among older adults, Black race, dementia, rural/nonurban residence, prescription of long-acting opioids, unmarried status, and use of muscle relaxants were variably associated (<75% agreement) with long-term opioid use.

Six studies examined factors associated with opioid-related disorders, although only one study evaluated factors associated with opioid use disorder. Alcohol misuse and gender were variably associated with opioid misuse (examined by three studies each).

All other evaluations of specific pairs of associated factors and outcomes of interest were evaluated by only one or two studies each. These included analyses of factors associated with multiple opioid prescribers, mental health outcomes, physical health outcomes, all-cause hospitalization, opioid-related hospitalization, nonopioid-specific hospitalization, emergency department visits, opioid overdose, all-cause death, opioid-related death, and nonopioid-related death.

The evidence on interventions directed at older adults is sparse. Of the 16 studies of opioid-related interventions in older adults, six examined screening tools to predict opioid-related harms, but none of these tools was tested in clinical practice to assess real-world results. Two studies found that prescription drug monitoring programs are associated with less opioid use in communities. Other studied interventions include multidisciplinary pain education for patients, an educational pamphlet for patients, implementation of an opioid safety initiative, provision of patient information and pain management training for clinicians, a bundle of educational modalities for clinicians, free prescription acetaminophen, a nationally mandated tamper-resistant opioid formulation, and motivational interview training for nursing students. Few intervention studies evaluated pain or other patient-centered outcomes such as disability and functioning.

Conclusions. The evidence base that is directly applicable to older adults who are prescribed opioids or have opioid-related disorders is limited. Fundamental research is necessary to determine which factors may predict clinically important, patient-centered, opioid-related outcomes. Studies to date have identified numerous possible factors associated with long-term opioid use (whether appropriate or not), but analyses of other opioid-related outcomes in older adults are relatively sparse. Research is also needed to identify interventions to reduce opioid prescribing where harms outweigh benefits (including screening tools), reduce opioid-related harms and disorders, and treat existing misuse or opioid use disorder among older adults.

Author/s:

Agency for Healthcare Research and Quality

Statin Use Over 65 Years of Age and All-Cause Mortality: A 10-Year Follow-Up of 19 518 People

Brian Desmarais — Sat, 14 Mar 2020 20:02:11 +0000

Date Added:

March 14, 2020

Journal/Publication:

Journal of the American Geriatrics Society

Publication Date:

October 1, 2019

Issue:

Volume:

URL:

Statin Use Over 65 Years of Age and All-Cause Mortality: A 10-Year Follow-Up of 19 518 People

Type:

Meta-analyses, Reviews, and Guidelines, Practice Management Reviews and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1111/jgs.16060

Keywords

all-cause mortality

cardiovascular events

hypercholesterolemia

older adults

primary prevention

MeSH

Hydroxymethylglutaryl-CoA Reductase Inhibitors

cardiovascular diseases

Statins appear to significantly reduce all-cause mortality in patients over 65 and in those over 75 as well. James W. Mold, MD, MPH

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Abstract

OBJECTIVES

As life expectancy continues to rise, the burden of cardiovascular disease among older people is expected to increase, making cardiovascular prevention in older people an issue of growing interest and public health importance. We aimed to explore the long‐term effects of adherence to statins on mortality and cardiovascular morbidity among older adults.

DESIGN

A historical population‐based cohort study using routinely collected data.

SETTING

Clalit Health Services Northern District.

PARTICIPANTS

We followed members of Clalit Health Services aged 65 years or older who were eligible for primary cardiovascular prevention for a period of 10 years.

MEASUREMENTS

We fitted Cox regression models to assess the association between the adherence to statin therapy and all‐cause mortality and cardiovascular morbidity, adjusting for cardiovascular risk factors and associated morbidity as time‐updated variables.

RESULTS

The analysis included 19 518 older adults followed during 10 years (median = 9.7 y). All‐cause mortality rates were 34% lower among those who had adhered to statin treatment, compared with those who had not (hazard ratio [HR] = .66; 95% confidence interval [CI] = .56‐.79). Adherence to statins was also associated with fewer atherosclerotic cardiovascular disease events (HR = .80; 95% CI = .71‐.81). The benefit of statin use did not diminish among beyond age 75 and was evident for both women and men.

CONCLUSION

Adherence to statins may be associated with reduced mortality and cardiovascular morbidity among older adults, regardless of age and sex. J Am Geriatr Soc 67:2038–2044, 2019

Author/s:

Eilat-Tsanani, S., Schonmann, Y., Mor, E.

Assessing and Counseling the Older Driver: A Concise Review for the Generalist Clinician

John Bayhi — Fri, 02 Aug 2019 18:51:18 +0000

Date Added:

August 9, 2019

Journal/Publication:

Mayo Clinic Proceedings

Publisher:

Mayo Foundation for Medical Education and Research

Publication Date:

August 1, 2019

Issue:

Volume:

Pages:

1582–1588

URL:

Assessing and Counseling the Older Driver: A Concise Review for the Generalist Clinician

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.mayocp.2019.03.023

Keywords

MeSH

referral and consultation

A concise review of issues and counseling strategies relevant to older drivers. James W. Mold, MD, MPH

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Older drivers are putting more miles on the road during their “golden years” than generations prior. Many older adults have safe driving habits, but unique age-related changes increase the risk for crash-related morbidity and mortality. Generalists are poised to assess and guide older adults' driving fitness. Although there is no uniformly accepted tool for driving fitness, assessment of 5 key domains (cognition, vision, physical function, medical comorbidities, and medications) using valid tools can help clinicians stratify older drivers into low, intermediate, and high risk for unsafe driving. Clinicians can then make recommendations about fitness to drive and appropriate referrals for rehabilitation or alternative transportation resources to optimize mobility, independence, and quality of life for older adults.

Author/s:

Hill, Larisa J.N., Pignolo, Robert J., Tung, Ericka E.

Medication Overload: America’s Other Drug Problem. How the drive to prescribe is harming older adults.

Brian Desmarais — Mon, 01 Jul 2019 14:26:58 +0000

Date Added:

January 21, 2021

Publisher:

Lown Institute

Publication Date:

July 1, 2019

URL:

Medication Overload: America’s Other Drug Problem How the drive to prescribe is harming older adults

Type:

Public Health Announcements

Format:

Web Page

Keywords

MeSH

Antineoplastic Combined Chemotherapy Protocols

Daunorubicin

Etoposide

substance-related disorders

Polypharmacy is a major problem in the U.S. This report summarizes its magnitude, causes, and consequences. Other evidence suggests that when the number of meds increases beyond 4-5, any possible benefits are outweighed by the risks of adverse effects and drug-drug interactions. Medication lists should include OTCs and should be updated at every visit. Patients should be strongly encouraged to bring their medication bottles with them to every visit. James W. Mold, MD, MPH

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In the last year, older adults in the U.S. sought medical care nearly 5 million times due to serious side effects from one or more medications. More than a quarter million of these visits resulted in hospitalizations, at a cost of $3.8 billion (see Appendix A in the full report). These numbers point to a rapidly growing epidemic of medication overload among older Americans. Over the last decade, adults age 65 and older have been hospitalized for serious drug side effects, called adverse drug events (ADEs), about 2 million times. To put this in context, there were 3.2 million opioid-related hospitalizations across the entire population during the same period.1 The trend of increasing ADEs is not propelled by drug abuse, but by the rising number of medications prescribed to older adults (called “polypharmacy” in the scientific literature). More than 40 percent of older adults take five or more prescription medications a day, a threefold increase over the past two decades.2,3 The greater the number of medications—most of which are prescribed for legitimate reasons—the greater the risk for serious adverse reactions in older patients. Medication overload is causing widespread yet unseen harm to our parents and our grandparents. It is every bit as serious as the opioid crisis, yet its scope remains invisible to many patients and health care professionals. While some clinicians are trying to reduce the burden of medications on their individual patients, no professional group, public organization, or government agency to date has formally assumed responsibility for addressing this national problem. If current trends continue, we estimate that medication overload will be responsible for at least 4.6 million hospitalizations between 2020 and 2030. It will cost taxpayers, patients and families an estimated $62 billion. Over the next decade, medication overload is expected to cause the premature death of 150,000 older Americans. In this report, the Lown Institute calls for the development of a national strategy to address medication overload and help older people avoid its devastating effects on the quality and length of their lives. A subsequent National Action Plan for Addressing Medication Overload will lay out a national strategy to address the epidemic of prescribing and ensure the safety of millions of older adults who are now at risk of preventable harm and premature death.

Author/s:

Executive Summary of the Lown Institute

Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain The SPACE Randomized Clinical Trial

Tracy Ashby — Mon, 07 Jan 2019 06:00:00 +0000

Date Added:

January 21, 2021

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

March 6, 2018

Issue:

Volume:

319

Pages:

872-882

URL:

Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain The SPACE Randomized Clinical Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jama.2018.0899

Keywords

PMID (1):

29509867

MeSH

Analgesics

analgesics, opioid

analgesics, non-narcotic

chronic pain

osteoarthritis, knee

In this RCT, comparing non-opioids to opioids for management of chronic pain in the lower back or knee due to OA the researchers found that non-opioid medications were more effective for relieving pain with fewer side effects.

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Importance Limited evidence is available regarding long-term outcomes of opioids compared with nonopioid medications for chronic pain.

Objective To compare opioid vs nonopioid medications over 12 months on pain-related function, pain intensity, and adverse effects.

Design, Setting, and Participants Pragmatic, 12-month, randomized trial with masked outcome assessment. Patients were recruited from Veterans Affairs primary care clinics from June 2013 through December 2015; follow-up was completed December 2016. Eligible patients had moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use. Of 265 patients enrolled, 25 withdrew prior to randomization and 240 were randomized.

Interventions Both interventions (opioid and nonopioid medication therapy) followed a treat-to-target strategy aiming for improved pain and function. Each intervention had its own prescribing strategy that included multiple medication options in 3 steps. In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response.

Main Outcomes and Measures The primary outcome was pain-related function (Brief Pain Inventory [BPI] interference scale) over 12 months and the main secondary outcome was pain intensity (BPI severity scale). For both BPI scales (range, 0-10; higher scores = worse function or pain intensity), a 1-point improvement was clinically important. The primary adverse outcome was medication-related symptoms (patient-reported checklist; range, 0-19).

Results Among 240 randomized patients (mean age, 58.3 years; women, 32 [13.0%]), 234 (97.5%) completed the trial. Groups did not significantly differ on pain-related function over 12 months (overall P = .58); mean 12-month BPI interference was 3.4 for the opioid group and 3.3 for the nonopioid group (difference, 0.1 [95% CI, −0.5 to 0.7]). Pain intensity was significantly better in the nonopioid group over 12 months (overall P = .03); mean 12-month BPI severity was 4.0 for the opioid group and 3.5 for the nonopioid group (difference, 0.5 [95% CI, 0.0 to 1.0]). Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall P = .03); mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group (difference, 0.9 [95% CI, 0.3 to 1.5]).

Conclusions and Relevance Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.

Trial Registration clinicaltrials.gov Identifier: NCT01583985

Author/s:

Krebs, Erin E., Gravely, Amy, Nugent, Sean, Jensen, Agnes C., DeRonne, Beth, Goldsmith, Elizabeth S., Kroenke, Kurt, Bair, Matthew J, Noorbaloochi, Siamak