Telephone counselling in patients for polypharmacy

This study was set up to investigate the effects of compliance and periodic telephone counselling by a pharmacist, on mortality in patients receiving polypharmacy.

It was a  randomised controlled trial in a hospital medical clinic. Five hundred and two of 1011 patients receiving five or more drugs for chronic disease found to be non-compliant at the screening visit were invited for randomisation to either a telephone counselling group.

The primary outcome was all-cause mortality in the randomised patients. Associations between compliance and mortality in the entire cohort of 1011 patients were also examined. Patients were defined as compliant with a drug if they took 80-120% of the prescribed daily dose. To calculate a compliance score for the whole treatment regimen, the number of drugs that the patient was fully compliant with was divided by the total number of prescribed drugs and expressed as a percentage. Only patients who complied with all recommended drugs were considered compliant.

Sixty of the 502 eligible patients defaulted and only 442 patients were randomised. After two years, 52% of the defaulters had died, but 17% of the control group and 11% of the intervention group had died. After adjustment for confounders, telephone counselling was associated with a 41% reduction in the risk of death. The number needed to treat to prevent one death at two years was 16. Other predictors included old age, living alone, rate of admission to hospital, compliance score, number of drugs for chronic disease, and non-treatment with lipid lowering drugs at the screening visit.

In the cohort of 1011 patients, the adjusted relative risk for death was 1.61 and 2.87  in patients with compliance scores of 34-66% and 0-33%, respectively, compared with those who had a compliance score of 67% or more.

In conclusion; in patients receiving polypharmacy, poor compliance was associated with a greatly increased mortality. Periodic telephone counselling by a pharmacist improved compliance and reduced mortality.

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Ageism and stroke

Fairhead and Rothwell in the BMJ investigated the management of transient ischaemic attacks and minor stroke in routine clinical services compared with a nested population receiving care based on national clinical practice guidelines.

In the routine service they found substantial under-referral for carotid artery imaging and subsequent undertreatment of symptomatic carotid artery stenosis in patients over the age of 80. The two study populations were comparable in terms of age, sex, and socioeconomic status and, for patients under 80, similar rates of performing clinical investigations were seen. Avoiding a disabling stroke is a priority in all patients, irrespective of age, and the authors conclude that the older patients in the population given routine care were discriminated against.

A qualitative study of the management of cardiovascular disease also identified ageism as a factor in suboptimal care for older people in that it showed that doctors felt uncertain about the best and safest clinical practice, were unaware of the latest relevant research evidence, and were hampered by problems with local services.

At the heart of the educational argument for stroke lies the counterintuitive notion that carotid endarterectomy for symptomatic carotid artery stenosis confers greater benefit for older people by virtue of their higher absolute risk for future stroke. Stroke specialists have a responsibility to disseminate these principles of good practice actively in their local healthcare communities. One way is to redesign stroke services and to integrate specialist and primary care responses to the management of transient ischaemic attacks in a similar manner to the approaches developed for coronary heart disease, which have led to a welcome reduction in the degree of related ageism.

Ageism will always prosper when resources are inadequate for the target population. The UK government has recently been embarrassed into action by a damning report from the National Audit Office that highlighted deficiencies in specialist stroke services nationally.

In England some early progress has been made, almost certainly due to a policy initiative delivered through the National Service Framework for Older People since 2001. Mortality from coronary heart disease and cancer declined between 1993 and 2003, and access to elective surgery increased between 2000 and 2003.

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Anaemia in older people

A large cohort study has indicated that anaemia may be independently associated with increased mortality. The study  recruited people aged 65 years or older in four communities in the USA.

Deaths were identified from databases, and by bi-annual follow up, up to mid-2001. Analysis was by quintile of haemoglobin level, and by use of the WHO criteria for anaemia. Baseline haemoglobin measurements were available of 5,800 participants, average age 74 years at baseline, with a median follow up of 11.2 years, and 54,000 person-years of follow up. Using WHO criteria, 8.5% were anaemic Anaemia was commoner in black participants (18%) than white (7.0%), but similar in men and women.

Participants in the lowest quintile of haemoglobin were older, more likely to be black, and had more comorbid conditions. The strongest correlates were with low BMI, low activity levels, fair or poor self reported health, frailty, heart failure, stroke, or transient ischaemic attack.

Death rates over the 11 years were 57% for those with WHO-defined anaemia but 39% for those without anaemia, with high levels of statistical significance, and for both cardiovascular and non-cardiovascular causes of death, using adjustments for a wide range of possibly confounding characteristics. The prevalence of anaemia was 8.5%.

The study clearly associates lower haemoglobin levels with increased mortality in a reasonably large population over a long time. The association with higher mortality was particularly strong using the WHO criteria for anaemia for women and men.

There is much we do not know, of course. We do not know the cause of anaemia in these people, and no observational study can determine causality. We can speculate that long-term anaemia can contribute to adverse physiological changes. We can only guess at the moment whether treating the anaemia would be beneficial in older people, as it is in specific conditions.

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