LETTERS TO THE EDITOR RESEARCH AGEISM IN STUDIES OF REHABILITATION IN PARKINSON’S DISEASE To the Editor: Parkinson’s disease (PD) affects 6.3 million people worldwide and has an estimated cost of $4 billion per year.1 Age is the single biggest risk factor, with prevalence increasing from 0.6% of the population in those aged 65 to 69 to 2.6% of those aged 85 to 89.2 Ageism is evident in the pharmacological management of PD; almost half of clinical trials using medications excluded participants based on age.3 The average age of individuals enrolled in these trials was 62, despite this group representing less than one-quarter of individuals treated for PD. Rehabilitation is another important aspect of treatment for PD. Rehabilitation improves quality of life and motor performance.4 It is not clear whether ageism is also a factor in studies of rehabilitation of PD. The current study was an analysis of the current literature to assess whether ageism is a factor in the design of studies of rehabilitation in PD.
METHODS The Cochrane Database of Systematic Reviews was used to evaluate all systematic reviews under the search terms “physiotherapy in Parkinson’s disease,” “occupational therapy in Parkinson’s disease,” and “speech therapy in Parkinson’s disease.” Five reviews were identified between 2001 and 2013. The inclusion criteria for including a randomized controlled trial (RCT) from selected reviews in the study were that it included only participants with PD; reported the mean age of participants in the paper, abstract, or in the Cochrane review tables; and was published in English.
RESULTS All five systematic reviews, containing 56 RCTs, were included in the study; eight RCTs were excluded because they did not include baseline characteristics. The mean of the mean ages of patients included the 48 trials was 68.1. The gender ratio, where included, was 65.6% male and 33.4% female. Of the 48 included trials, 34 had documented exclusion criteria. Age was an inclusion criterion in six (18%) studies. One study excluded individuals aged 85 and older, three excluded individuals aged 80 and older, and two excluded individuals aged 75 and older. Eighteen RCTs (53%) excluded individuals with dementia, with one trial requiring an MMSE score greater than 26 as an inclusion criteria.
JAGS 63:1470–1492, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society
Table 1. Exclusion Criteria Documented in Studies Criterion
Age Dementia Disability Neurological disease Cardiovascular disease Musculoskeletal disease
n (%)
6 18 6 9 8 8
(18) (53) (18) (26) (24) (24)
Disability was noted as an exclusion factor in six RCTs (18%) requiring participants to be independently mobile without the use of walking aids. Comorbidities were also exclusion criteria in a significant minority of studies, with nine (26%) excluding individuals with other neurological diseases such as stroke and eight (24%) each excluding those with musculoskeletal disease and cardiovascular disease (Table 1).
DISCUSSION This review of rehabilitation studies shows that the mean age of study participants is not representative of the population most at need. The peak age for prevalence of PD is 70 to 79, but the mean age in the RCTs of rehabilitation (68.1) does not reflect this.5 One in 35 people aged 80 and older has PD, and the biggest predictor of motor disability in PD is age at onset.6 Although the sex ratio is similar to current clinical experience, with more men than women,7 many of the trials also exclude significant numbers with complex disability, particularly disorders of cognition and comorbidity. The majority of people who have PD for 15 years or longer have severe motor disability,8 and approximately one-quarter have cognitive impairment.9 The absence of these individuals means that application of trial data on rehabilitation in PD in clinical practice is degraded. Age was an exclusion factor in only 18% of studies, although when the range of comorbid medical conditions excluded is taken into account, it is evident that ageism exists. Participants in clinical trials in rehabilitation in PD must more closely resemble those seen in everyday practice. Although one could argue that these trials were compiled in an era during which there was less sensitivity to the needs of individuals with dementia, 32 trials were completed in the last 15 years. With advancing age, stroke, decreasing mobility, and multiple comorbidities become more widespread and should not preclude inclusion in clinical trials. These factors need to be factored into future trial designs, which would mean that researchers will need to use more-complex assessment and consent, although the vulnerable individuals who account for the majority of people living with PD need to be adequately represented in clinical trials to ensure the development of evidenced-based rehabilitation methods.
0002-8614/15/$15.00
JAGS
JULY 2015–VOL. 63, NO. 7
Mary Buckley, MB Desmond O’Neill, MD Centre for Ageing, Neuroscience and the Humanities, Tallaght Hospital, Dublin, Ireland
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors contributed to this paper. Sponsor’s Role: None.
REFERENCES 1. Rascol O, Lozano A, Stern M et al. Milestones in Parkinson’s disease therapeutics. Mov Disord 2011;26:1072–1082. 2. De Rijk MC, Launer LJ, Berger K et al. Prevalence of Parkinson’s disease in Europe: A collaborative study of population based cohorts. Neurology 2000;54(11 Suppl 5):S21–S23. 3. Fitzsimmons PR, Blayney S, Mina-Corkill S et al. Older participants are frequently excluded from Parkinson’s disease research. Parkinsonism Rel Disord 2012;18:585–589. 4. Gage H, Storey L. Rehabilitation for Parkinson’s disease: A systematic review of available evidence. Clin Rehabil 2004;18:463–482. 5. Pringsheim T, Jette N, Frolkis A et al. The prevalence of Parkinson’s disease: A systematic review and meta-analysis. Mov Disord 2014;29:1583–1590. 6. Alves G, Wentzel-Larsen T, Aarsland D et al. Progression of motor impairment and disability in Parkinson disease: A population-based study. Neurology 2005;65:1436–1441. 7. Zhang ZX, Roman GC. Worldwide occurrence of Parkinson’s disease: An updated review. Neuroepidemiology 1993;12:195–208. 8. Hely MA, Morris JG, Reid WG et al. Sydney Multicentre Study of Parkinsons Disease: Non L-dopa responsive problems dominate at 15 years. Mov Disord 2005;20:190–199. 9. Aarsland D, Zaccai J, Brayne C. A systematic review of prevalence studies of dementia in Parkinson’s disease. Mov Disord 2005;20:1255–1263.
PREVALENCE OF POTENTIALLY INAPPROPRIATE PRESCRIBING AMONG HONG KONG OLDER ADULTS: A COMPARISON OF THE BEERS 2003, BEERS 2012, AND SCREENING TOOL OF OLDER PERSON’S PRESCRIPTIONS AND SCREENING TOOL TO ALERT DOCTORS TO RIGHT TREATMENT CRITERIA To the Editor: Older adults with multiple chronic comorbidities must take multiple medications. Polypharmacy, defined as concurrent use of five or more medications,1 is common in older adults. Inappropriate prescribing can put older adults at risk of adverse drug events.2 Screening tools, such as the Beers criteria3–5 and the Screening Tool of Older Person’s Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria,6 are commonly used to identify potentially inappropriate prescribing (PIP). The prevalence of PIP globally, accordingly to these criteria, ranges from 13% to 35%.7 Previous studies assessing prescribing appropriateness were conducted using the Beers 2003 criteria only.8,9 The objectives of the current study were to determine the prevalence of PIP as identified by Beers 2003, Beers 2012, and STOPP criteria in Hong
LETTERS TO THE EDITOR
1471
Kong older adults; to evaluate the ability of the three sets of criteria to identify PIP; and to investigate the association between the number of medications prescribed and PIP. A cross-sectional, retrospective, observational study was conducted in an acute care tertiary hospital in Hong Kong. Five hundred individuals aged 65 and older admitted to the medical wards were randomly recruited from January 2013 to December 2013. Preadmission medications that were currently prescribed were assessed for each eligible individual. Over-the-counter medications, herbal medications, and vitamin supplements were not considered because none of the criteria have included these medications. Frequency of PIP (whether potentially inappropriate medications (PIMs) or potential prescribing omissions (PPOs)) was tabulated after each participant’s list of medications was measured against the Beers and STOPP/START criteria. Statistical analyses were performed using SPSS Statistics version 20 (IBM, Corp, Armonk, NY). The Wilcoxon signed rank test was used to compare the prevalence of PIP that each set of criteria identified. The Spearman rho correlation test was used to evaluate the association between number of medications and PIP that the criteria identified. P < .05 was considered statistically significant. Of the 500 individuals recruited, 246 (49.2%) were male, and the mean age standard deviation was 81.4 8.6. Three thousand nine hundred ninety-seven medication items were reviewed, with a mean of 8.0 4.5 medications per person. Three hundred eighty-nine participants (77.8%) uses more than five medications daily. When the Beers 2003 criteria were used to assess PIP, 179 (35.8%) participants with 233 PIMs were identified. When the Beers 2012 criteria were used, 193 (38.6%) participants with 374 PIMs were identified. According to the STOPP and START criteria, 158 (31.6%) participants with 220 PIMs and 251 (50.2%) participants with 423 PPOs were identified, respectively. Frequencies of PIP that each set of criteria identified are listed in Table 1. There was no significant difference between the amount of PIP that the Beers 2003 or STOPP criteria identified (Z = 0.89, P = .38), but there was a significant difference when the Beers 2012 criteria were compared with the Beers 2003 (Z = 4.58 P < .001) or STOPP (Z = 5.84 P < .001) criteria. Using the Spearman rho correlation test, a positive association (0.38 Beers 2003, 0.35 Beers 2012, 0.34 STOPP; all P < .001) was found between number of medications use and amount of PIP identified.
Table 1. Number of Participants Identified with Potentially Inappropriate Medication (PIM) or Potential Prescribing Omission (PPO) According to the Various Criteria Number of PIMs or PPOs
0 1 2 3 ≥4
Beers 2003
Beers 2012
Screening Tool of Older Person’s Prescriptions
321 137 36 4 2
307 110 42 15 26
342 117 27 10 4
Screening Tool to Alert doctors to Right Treatment
249 135 78 27 11
METHODS The Cochrane Database of Systematic Reviews was used to evaluate all systematic reviews under the search terms “physiotherapy in Parkinson’s disease,” “occupational therapy in Parkinson’s disease,” and “speech therapy in Parkinson’s disease.” Five reviews were identified between 2001 and 2013. The inclusion criteria for including a randomized controlled trial (RCT) from selected reviews in the study were that it included only participants with PD; reported the mean age of participants in the paper, abstract, or in the Cochrane review tables; and was published in English.
RESULTS All five systematic reviews, containing 56 RCTs, were included in the study; eight RCTs were excluded because they did not include baseline characteristics. The mean of the mean ages of patients included the 48 trials was 68.1. The gender ratio, where included, was 65.6% male and 33.4% female. Of the 48 included trials, 34 had documented exclusion criteria. Age was an inclusion criterion in six (18%) studies. One study excluded individuals aged 85 and older, three excluded individuals aged 80 and older, and two excluded individuals aged 75 and older. Eighteen RCTs (53%) excluded individuals with dementia, with one trial requiring an MMSE score greater than 26 as an inclusion criteria.
JAGS 63:1470–1492, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society
Table 1. Exclusion Criteria Documented in Studies Criterion
Age Dementia Disability Neurological disease Cardiovascular disease Musculoskeletal disease
n (%)
6 18 6 9 8 8
(18) (53) (18) (26) (24) (24)
Disability was noted as an exclusion factor in six RCTs (18%) requiring participants to be independently mobile without the use of walking aids. Comorbidities were also exclusion criteria in a significant minority of studies, with nine (26%) excluding individuals with other neurological diseases such as stroke and eight (24%) each excluding those with musculoskeletal disease and cardiovascular disease (Table 1).
DISCUSSION This review of rehabilitation studies shows that the mean age of study participants is not representative of the population most at need. The peak age for prevalence of PD is 70 to 79, but the mean age in the RCTs of rehabilitation (68.1) does not reflect this.5 One in 35 people aged 80 and older has PD, and the biggest predictor of motor disability in PD is age at onset.6 Although the sex ratio is similar to current clinical experience, with more men than women,7 many of the trials also exclude significant numbers with complex disability, particularly disorders of cognition and comorbidity. The majority of people who have PD for 15 years or longer have severe motor disability,8 and approximately one-quarter have cognitive impairment.9 The absence of these individuals means that application of trial data on rehabilitation in PD in clinical practice is degraded. Age was an exclusion factor in only 18% of studies, although when the range of comorbid medical conditions excluded is taken into account, it is evident that ageism exists. Participants in clinical trials in rehabilitation in PD must more closely resemble those seen in everyday practice. Although one could argue that these trials were compiled in an era during which there was less sensitivity to the needs of individuals with dementia, 32 trials were completed in the last 15 years. With advancing age, stroke, decreasing mobility, and multiple comorbidities become more widespread and should not preclude inclusion in clinical trials. These factors need to be factored into future trial designs, which would mean that researchers will need to use more-complex assessment and consent, although the vulnerable individuals who account for the majority of people living with PD need to be adequately represented in clinical trials to ensure the development of evidenced-based rehabilitation methods.
0002-8614/15/$15.00
JAGS
JULY 2015–VOL. 63, NO. 7
Mary Buckley, MB Desmond O’Neill, MD Centre for Ageing, Neuroscience and the Humanities, Tallaght Hospital, Dublin, Ireland
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors contributed to this paper. Sponsor’s Role: None.
REFERENCES 1. Rascol O, Lozano A, Stern M et al. Milestones in Parkinson’s disease therapeutics. Mov Disord 2011;26:1072–1082. 2. De Rijk MC, Launer LJ, Berger K et al. Prevalence of Parkinson’s disease in Europe: A collaborative study of population based cohorts. Neurology 2000;54(11 Suppl 5):S21–S23. 3. Fitzsimmons PR, Blayney S, Mina-Corkill S et al. Older participants are frequently excluded from Parkinson’s disease research. Parkinsonism Rel Disord 2012;18:585–589. 4. Gage H, Storey L. Rehabilitation for Parkinson’s disease: A systematic review of available evidence. Clin Rehabil 2004;18:463–482. 5. Pringsheim T, Jette N, Frolkis A et al. The prevalence of Parkinson’s disease: A systematic review and meta-analysis. Mov Disord 2014;29:1583–1590. 6. Alves G, Wentzel-Larsen T, Aarsland D et al. Progression of motor impairment and disability in Parkinson disease: A population-based study. Neurology 2005;65:1436–1441. 7. Zhang ZX, Roman GC. Worldwide occurrence of Parkinson’s disease: An updated review. Neuroepidemiology 1993;12:195–208. 8. Hely MA, Morris JG, Reid WG et al. Sydney Multicentre Study of Parkinsons Disease: Non L-dopa responsive problems dominate at 15 years. Mov Disord 2005;20:190–199. 9. Aarsland D, Zaccai J, Brayne C. A systematic review of prevalence studies of dementia in Parkinson’s disease. Mov Disord 2005;20:1255–1263.
PREVALENCE OF POTENTIALLY INAPPROPRIATE PRESCRIBING AMONG HONG KONG OLDER ADULTS: A COMPARISON OF THE BEERS 2003, BEERS 2012, AND SCREENING TOOL OF OLDER PERSON’S PRESCRIPTIONS AND SCREENING TOOL TO ALERT DOCTORS TO RIGHT TREATMENT CRITERIA To the Editor: Older adults with multiple chronic comorbidities must take multiple medications. Polypharmacy, defined as concurrent use of five or more medications,1 is common in older adults. Inappropriate prescribing can put older adults at risk of adverse drug events.2 Screening tools, such as the Beers criteria3–5 and the Screening Tool of Older Person’s Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria,6 are commonly used to identify potentially inappropriate prescribing (PIP). The prevalence of PIP globally, accordingly to these criteria, ranges from 13% to 35%.7 Previous studies assessing prescribing appropriateness were conducted using the Beers 2003 criteria only.8,9 The objectives of the current study were to determine the prevalence of PIP as identified by Beers 2003, Beers 2012, and STOPP criteria in Hong
LETTERS TO THE EDITOR
1471
Kong older adults; to evaluate the ability of the three sets of criteria to identify PIP; and to investigate the association between the number of medications prescribed and PIP. A cross-sectional, retrospective, observational study was conducted in an acute care tertiary hospital in Hong Kong. Five hundred individuals aged 65 and older admitted to the medical wards were randomly recruited from January 2013 to December 2013. Preadmission medications that were currently prescribed were assessed for each eligible individual. Over-the-counter medications, herbal medications, and vitamin supplements were not considered because none of the criteria have included these medications. Frequency of PIP (whether potentially inappropriate medications (PIMs) or potential prescribing omissions (PPOs)) was tabulated after each participant’s list of medications was measured against the Beers and STOPP/START criteria. Statistical analyses were performed using SPSS Statistics version 20 (IBM, Corp, Armonk, NY). The Wilcoxon signed rank test was used to compare the prevalence of PIP that each set of criteria identified. The Spearman rho correlation test was used to evaluate the association between number of medications and PIP that the criteria identified. P < .05 was considered statistically significant. Of the 500 individuals recruited, 246 (49.2%) were male, and the mean age standard deviation was 81.4 8.6. Three thousand nine hundred ninety-seven medication items were reviewed, with a mean of 8.0 4.5 medications per person. Three hundred eighty-nine participants (77.8%) uses more than five medications daily. When the Beers 2003 criteria were used to assess PIP, 179 (35.8%) participants with 233 PIMs were identified. When the Beers 2012 criteria were used, 193 (38.6%) participants with 374 PIMs were identified. According to the STOPP and START criteria, 158 (31.6%) participants with 220 PIMs and 251 (50.2%) participants with 423 PPOs were identified, respectively. Frequencies of PIP that each set of criteria identified are listed in Table 1. There was no significant difference between the amount of PIP that the Beers 2003 or STOPP criteria identified (Z = 0.89, P = .38), but there was a significant difference when the Beers 2012 criteria were compared with the Beers 2003 (Z = 4.58 P < .001) or STOPP (Z = 5.84 P < .001) criteria. Using the Spearman rho correlation test, a positive association (0.38 Beers 2003, 0.35 Beers 2012, 0.34 STOPP; all P < .001) was found between number of medications use and amount of PIP identified.
Table 1. Number of Participants Identified with Potentially Inappropriate Medication (PIM) or Potential Prescribing Omission (PPO) According to the Various Criteria Number of PIMs or PPOs
0 1 2 3 ≥4
Beers 2003
Beers 2012
Screening Tool of Older Person’s Prescriptions
321 137 36 4 2
307 110 42 15 26
342 117 27 10 4
Screening Tool to Alert doctors to Right Treatment
249 135 78 27 11
