Psychotropic Polypharmacy among Elderly Patients with Mental Illness in a Malaysian University Hospital: A 10-Year Review of Hospital Databases

Psychotropic polypharmacy among elderly patients is problematic due to their multiple comorbidities. This study investigated psychotropic polypharmacy among elderly patients discharged from a Malaysian university hospital and its associated factors. Discharges of patients aged 65 years or above from the psychiatric wards from 2010 to 2019 were reviewed. Sociodemographic data, length of stay (LOS), psychiatric and other diagnoses, and psychotropic prescription upon discharge were extracted from electronic databases. Multiple logistic regression was conducted with age, gender, race, marital status, main psychiatric diagnosis, LOS, and the number of medical comorbidities as independent variables, and polypharmacy (>2 psychotropics) as the dependent variable. There were 354 discharges in this period. The mean age was 72.4 years (SD=5.9 years); 63.0% were female and 39.8% were Malays. Most were married (84.2%). The commonest category of psychiatric diagnosis was mood disorders (54.5%). A total of 76.8% of the discharges involved one or more medical comorbidities. The median number of psychotropics was two, with 38.1% prescribed three or more psychotropics. In the multiple regression model, female gender, Malay race, and being married were significantly associated with psychotropic polypharmacy. Sociocultural factors may contribute to psychotropic polypharmacy among elderly patients. Such factors require further investigations to elucidate their roles.

Lithium Receipt and Risk of Dementia in Older Veterans With Bipolar Disorder in the VA Health System

Older adults with bipolar disorder are at increased risk of developing dementia. The literature suggests lithium treatment may reduce the incidence of dementia. This study sought to inform clinical practice in the Veterans Affairs (VA) health system by estimating the effect of past year lithium receipt on dementia incidence among Veterans with bipolar disorder. Divalproex receipt was used as a comparison. Using VA medical records, 121,094 Veterans aged 50 and older with a diagnosis of bipolar disorder but no dementia diagnosis were identified in fiscal years 2005-2019. Follow-up continued until dementia diagnosis, 36 months from the index date, death, or the end of fiscal year 2020, whichever came first. 4347 (3.6%) were diagnosed with dementia during follow-up. Time-varying indicators of receipt of lithium and divalproex in the prior 365 days were calculated for each day, categorized as 301-365, 61-300, 1-60, or 0 days of receipt. Unadjusted Cox proportional hazards regression analyses indicated reduced dementia incidence with 301-365 (HR=0.86, 95% Confidence Interval [95%CI] 0.75-0.99) and 61-300 (HR=0.75, 95%CI 0.65-0.87) days of lithium receipt, compared to 0 days. For divalproex, 301-365 (HR=1.34, 95%CI 1.23-1.47) and 61-300 (HR=1.13, 95%CI 1.03-1.23) days of receipt were each associated with increased dementia incidence. Lithium effects were not statistically significant after adjusting for age, sex, race, ethnicity, medical comorbidities, and antidepressant, antipsychotic, and anxiolytic medication receipt. Divalproex effects remained statistically significant. Past year divalproex, but not lithium, receipt was significantly associated with dementia incidence among VA patients with bipolar disorder when adjusting for demographics and medical comorbidities.

Screening Echocardiogram in High-Risk Women with Class III Obesity to Predict the Risk of Preeclampsia

Objective Women with obesity and other comorbidities such as hypertension and diabetes are at an increased risk of preeclampsia and perinatal morbidity. This study evaluates whether screening echocardiogram can identify women with obesity at a higher risk of preeclampsia. Methods We conducted a retrospective cohort study of women with class III obesity (body mass index [BMI] ≥40 kg/m2) and one or more medical comorbidities associated with an increased risk of preeclampsia (such as diabetes, hypertension, and rheumatologic disease) undergoing screening echocardiogram. Abnormal findings were defined as the presence of one or more of the following: diastolic dysfunction, ejection fraction of ≤45%, or cardiac chamber enlargement or hypertrophy. Multivariable logistic regression was used to estimate the odds ratio (OR) of gestational hypertension/mild preeclampsia, severe preeclampsia, and any preterm delivery <37 weeks associated with abnormal echocardiographic findings when controlling for potential confounders. Results Of 267 eligible women, 174 (64%) underwent screening echocardiograms. Sixty-nine women (40%) had abnormal echocardiograms. Maternal clinical characteristics were similar between women with normal echocardiographic findings and women with abnormal findings. Women with abnormal echocardiograms were more likely to have chronic hypertension (78 vs. 62%, p = 0.04) and a history of preeclampsia (27 vs. 10%, p = 0.02). After controlling for confounders, women with abnormal echocardiogram were at an increased risk of hypertensive disorders of pregnancy, OR 6.80 (95% confidence interval [CI] 3.32–13.93, p = 0.01), and in particular severe preeclampsia, OR 8.77 (95% CI 3.90–19.74, p = 0.01). Conclusion Among pregnant women with class III obesity and medical comorbidities, screening echocardiogram may help identify a subset of women at the highest risk of developing preeclampsia. Key Points

Crohn's Disease Increases In-Hospital Lengths of Stay, Medical Complications, and Costs of Care following Primary Total Knee Arthroplasty

The literature has shown an increase in prevalence of Crohn's disease (CD) within the United States alongside a concomitant rise in primary total knee arthroplasty (TKA) procedures. As such, with these parallel increases, orthopaedic surgeons will invariably encounter CD patients requiring TKA. Limited studies exist evaluating the impact of this disease on patients undergoing the procedure; therefore, this study endeavors to determine whether CD patients undergoing primary TKA have higher rates of (1) in-hospital lengths of stay (LOS), (2) medical complications, and (3) episode of care (EOC) costs. To accomplish this, a nationwide database was queried from January 1, 2005 to March 31, 2014 to identify patients undergoing TKA. The study group, patients with CD, was randomly matched to the controls, patients without CD, in a 1:5 ratio after accounting for age, sex, and medical comorbidities associated with CD. Patients consuming corticosteroids were excluded, as they are at risk of higher rates of adverse events following TKA. This query ultimately yielded a total of 96,213 patients, with 16,037 in the study cohort and 80,176 in the control one. The study compared in-hospital (LOS), 90-day medical complications, and day of surgery and total global 90-day EOC costs between CD and non-CD patients undergoing primary TKA. The results found CD patients undergoing primary TKA had significantly longer in-hospital LOS (4- vs. 3 days, p < 0.0001) compared with non-CD patients. CD patients were also found to have significantly higher incidence and odds of 90-day medical complications (25.31 vs. 10.75; odds ratio: 2.05, p < 0.0001) compared with their counterparts. Furthermore, CD patients were found to have significantly higher 90-day EOC costs ($15,401.63 vs. 14,241.15, p < 0.0001) compared with controls. This study demonstrated that, after adjusting for age, sex, and medical comorbidities, patients with CD have prolonged in-hospital LOS, increased medical complications, and higher EOC costs following primary TKA. Therefore, it establishes the importance for orthopaedists to adequately counsel CD patients of the potential complications and outcomes following their procedure.

Association of common medical comorbidities with early renal damage in the Chinese tropics with essential hypertension

Background Urine albumin/creatinine ratio (UACR) is an important marker of early renal damage (ERD) caused by hypertension. Recent studies showed that blood pressure was a significant inverse association with temperature and climate. The purposes of our study were sought to explore the association of common medical comorbidities with ERD, and find independent risk factors to ERD in Chinese tropics with essential hypertension. Methods From January 2018 to December 2019, we assessed UACR in a total of 599 hypertensive Chinese Hainan patients. We defined ERD as a UACR between 30 mg/g and 300 mg/g. We analysed differences between qualitative variables using the chi-squared (χ2) test. We calculated correlations between UACR and age, hypertension duration (HD), systolic blood pressure (SBP), and diastolic blood pressure (DBP) using the Spearman’s rho test. To determine the odds ratio (OR), we evaluated binary logistic regression models. Results Among the 599 patients, 281 (46.9%) were found to have ERD. ERD and factors related to sex, body mass index (BMI), and SBP did not differ significantly (all, p>0.05). Our main findings showed that age, HD, and DBP were associated with ERD (p<0.01, respectively). Furthermore, age ≥ 65 years, HD ≥10 years, DBP ≥ 90 mmHg, SBP ≥ 160 mmHg, and diabetes differed significantly according to ERD status (p < 0.05, respectively). In multivariate analysis using stepwise regression, age (OR = 1.468), DBP (OR = 1.853), and diabetes (OR = 2.031) were significant independent predictors of ERD. The area under the receiver operating characteristic (ROC) curve was 0.677, and the sensitivity and specificity of the optimal cut-off value were 44.5 and 81.1%, respectively. Conclusions Common medical comorbidities are associated with ERD; age, DBP, and diabetes are independent risk factors for ERD in patients with essential hypertension who live in the Chinese tropics. Early monitoring of the UACR, as well as control of blood glucose and DBP, can effectively delay ERD.

NCOG-21. PREDICTORS OF SURVIVAL IN ELDERLY PATIENTS UNDERGOING SURGERY FOR GBM

BACKGROUND An increasing number of elderly patients are being diagnosed with GBM and undergoing surgery. These patients often present with multiple medical comorbidities and have significantly worse outcomes compared to adult patients. The goal of this study was to determine clinical predictors of survival in elderly patients undergoing surgery for GBM. METHODS A retrospective chart review of all consecutive patients 65 years of age and older that underwent surgery for newly diagnosed GBM from 2005-2018 was performed. A total of 150 patients were included, and subdivided into two age categories; 65-74 and 75 or older. RESULTS Advanced age and medical comorbidities were not associated with decreased survival (p = 0.07 and p = 0.09, respectively). Postoperative complication was associated with worse survival for all patients (HR = 2.34, p = 0.01) and occurred in patients with longer lengths of stay (p &lt; 0.0001) and discharge destination other than home (p = 0.001). CONCLUSIONS The presence of medical comorbidities and advanced age are not reasons to exclude patients with GBM from surgical consideration. Postoperative complication is the most significant predictor of survival in elderly patients and can be avoided by a short length of stay and discharge home.