Hospitalisation represents an opportunity to optimise medication therapy in patients at high risk of medication-related harm. Quality Use of Medicines (QUM) activities are typically incorporated into routine care, yet their impact as part of usual inpatient practice has not been comprehensively synthesised. The aims of this systematic review were to determine the extent to which hospitalisation serves as an opportunity for improving QUM in older adults receiving usual inpatient care, explore barriers and facilitators influencing the implementation and sustainability of QUM activities during hospitalisation, and identify which components of usual care most effectively improve medication appropriateness and safety. We conducted a systematic review of observational studies, identified using Medline, Embase, and International Pharmaceutical Abstracts, from January 2010 to May 2025. Eligible studies included older adults (≥65 years) admitted to hospital for at least 24 hours, where healthcare professionals delivered QUM-related activities as part of usual care during hospitalisation. Measurable changes in medications between admission and discharge using QUM indicators were reported. Methodological quality was assessed using the Joanna Briggs Institute (JBI) cohort checklist and findings were synthesised narratively. Twenty-one studies met the inclusion criteria. Nineteen were rated as high quality and two as moderate quality. All studies evaluated changes in prescribing, most commonly using explicit tools such as the Beers criteria, Screening Tool to Alert to Right Treatment and guideline-based assessments of therapy. Ten studies showed usual care led to improvements in QUM indicators, including reduction in potentially inappropriate medicines (PIM) in settings with strong multidisciplinary involvement and structured medication reviews. However, 11 studies reported that QUM did not improve, with persistent or increased PIM use and polypharmacy at discharge. Factors contributing to ongoing QUM problems included limited clinician awareness, fragmented communication, inadequate documentation, constrained resources, poor integration of pharmacists, and variable use of QUM tools. Hospitalisation represents an important but inconsistently realised opportunity to optimise QUM in older adults. Inappropriate prescribing and polypharmacy frequently persist at discharge, indicating missed opportunities within usual care. System-level strategies embedding structured medication reviews, pharmacist involvement, explicit QUM tools, and robust documentation into routine practice may enhance medication safety.

Emerging evidence in animal models and humans suggests that statins may provide partial protection against noise-induced and drug-induced hearing loss. However, evidence for protection against age-related hearing loss (ARHL) is mixed, and longitudinal studies in large adult cohorts from the general population are limited. This study examined the association between statin use and ARHL in a diverse, community-based longitudinal cohort of adults across the lifespan. The 1239 participants, aged ≥ 55 years, are from the MUSC Longitudinal Cohort Study of Age-Related Hearing Loss (1988-present). Following a comprehensive baseline examination, participants attended annual examinations during which audiometric and statin use data were collected. Multivariable linear regression models were performed on baseline data for cross-sectional analyses, and general linear mixed models were performed on longitudinal data to assess the association between statin use, two types of statins, and hearing over time. Hearing outcomes include four pure-tone averages (PTA): narrow (0.5, 1.0, 2.0, and 4.0 kHz), low frequency (0.25, 0.5, and 1.0 kHz), broad (0.5, 1.0, 2.0, 3.0, 4.0, 6.0, and 8.0 kHz), and high frequency (2.0, 3.0, 4.0, 6.0, and 8.0 kHz). Missing covariate data were imputed with multiple imputation using chain equations (MICE). Statin use (versus no use) was associated with better hearing at baseline for the broad and high-frequency PTAs for adults aged 55-64 and 65-74 years. However, this statin benefit was not observed for the 75+-year age group and for all participants when hearing was examined over time. Without age stratification, similar results were observed for atorvastatin use but not for simvastatin use. Overall, the findings suggest statin benefits for mid-to-high frequency hearing for middle-aged to older adults at early stages of ARHL. On the basis of evidence suggesting that some statins have beneficial effects on hearing, well-controlled clinical trials are needed to examine effects of statin use and statin types on ARHL in the general population.

Transient or permanent cognitive changes among patients experiencing anesthesia, surgery, perioperative sleep disturbances, and the hospital environment in general have become an extensive topic of debate, particularly concerning older adults and individuals with pre-existing cognitive impairment. This narrative review advocates for an updated nomenclature and terminology in the classification of postoperative cognitive changes and summarizes the current understanding of the most important risk factors for postoperative delirium, focusing on patient-specific, anesthetic, and procedural aspects, including the impact of regional versus general anesthesia. Mounting evidence suggests that appropriate anesthetic depth as monitored by processed electroencephalogram (EEG) is important to preserve baseline postoperative cognitive function in vulnerable patients. The potential roles of cognitive prehabilitation, perioperative medications such as dexmedetomidine and antipsychotics, and early mobilization as well as maintenance of sleep quality for mitigating postoperative cognitive alterations are addressed to aid the practitioner in developing comprehensive care plans emphasizing brain health for this at-risk population. Current evidence highlights an urgent need for additional research in this domain of patient care. Targeted clinician education to understand the multifactorial and complex factors contributing to this perioperative conundrum is essential. Improvements in the prevention, monitoring, and treatment of postoperative cognitive alterations, especially in older adults with pre-existing cognitive conditions, remain an unmet need.

Psychotropic medications are associated with an increased risk of adverse drug events in older adults, yet national data on their use in Australia remain limited. This study aims to estimate the prevalence of psychotropic medication use among older Australians and to examine the sociodemographic factors associated with their use. A retrospective cross-sectional study was conducted using national linked data from the 2021 Census and the Pharmaceutical Benefits Scheme (PBS). The study included all individuals aged 65+ years who responded to the 2021 Census and received at least one PBS medication between 1 August and 31 October 2021. Prevalence of psychotropic medication use was calculated across 5-year age groups, and sociodemographic factors associated with each psychotropic subclass were assessed by logistic regression model. Among the 3,850,281 older adults, 31.1% received at least one psychotropic medication. Prevalence increased with age across all subclasses except antiepileptics. Antidepressants were the most commonly used psychotropics (19.9%). Those needing assistance with core activities (odds ratio, OR 2.05, 95% confidence intervals, CI 2.03-2.06) and living in non-private dwellings (OR 2.02, 95% CI 1.99-2.05) were more likely to receive psychotropics. Conversely, higher educational level, socioeconomic status and non-English speaker were associated with a lower use of all psychotropic subclasses. Aboriginal and Torres Strait Islander people were linked to increased use of benzodiazepines (OR, 1.15; 95% CI 1.10-1.20) and opioids (OR, 1.20; 95% CI 1.16-1.23). Dementia was strongly associated with antipsychotic (OR, 2.59; 95% CI 2.52-2.66) and antidepressant (OR, 1.42; 95% CI 1.40-1.44) use. Arthritis significantly increased the likelihood of opioid use (OR, 2.03; 95% CI 2.02-2.05). Almost one third of the study population used psychotropic medications between August and October 2021. Aboriginal and Torres Strait Islander people, individuals with dementia and those with arthritis had an increased likelihood of using certain psychotropic medications. Future research should evaluate the clinical appropriateness of psychotropics in these populations, with immediate implementation of strategies to ensure that their use is limited to evidence-based indications.

Scabies is a common and disabling ectoparasitic infestation of the skin that can clinically present in 'classical' or 'crusted' forms. Diagnosis can often be made on the basis of clinical history and careful dermoscopic examination of the skin. The International Alliance for the Control of Scabies (IACS) diagnostic criteria can support the diagnosis and management of patients with suspected scabies. Older adults are a vulnerable population; the clinical presentation of scabies can be atypical in this group and treatment can be challenging. Institutional scabies outbreaks, such as in care homes, are typically challenging to identify and, therefore, subject to diagnostic delay. These outbreaks are hard to control and an important source of morbidity, requiring simultaneous treatment of those affected, which can be complicated and time consuming. The management of scabies outbreaks involves repeated, contemporaneous (if multiple individuals) treatments with topical scabicide applications to the whole body, with decontamination of the environment(s). In some situations, topical treatment may be inappropriate and delay effective treatment.

Atopic dermatitis (AD) is a chronic inflammatory skin condition that can be particularly challenging to manage in older adults. Dupilumab, a monoclonal antibody targeting the interleukin-4 receptor alpha subunit, has shown promise in treating moderate to severe AD. However, its efficacy and safety in older adults with refractory AD have not been extensively studied. The objective of this study is to evaluate the efficacy and safety of dupilumab in treating older adults with refractory atopic dermatitis and to determine its potential as a therapeutic option in this demographic. A retrospective, single-center study was conducted involving 73 older adults (aged ≥ 60 years) with moderate-to-severe AD. The Eczema Area and Severity Index (EASI), Pruritus Numerical Rating Scales (P-NRS), and Dermatology Life Quality Index (DLQI) scores were recorded at baseline and at weeks 6 and 16. Adverse events (AEs) were also monitored. Following dupilumab treatment, a significant reduction in EASI, P-NRS, and DLQI scores was observed compared with baseline (p < 0.0001), indicating improved clinical symptoms and quality of life. Adverse events were mostly mild and did not lead to treatment discontinuation. Dupilumab demonstrates significant efficacy and a favorable safety profile in managing refractory AD in older adults, suggesting it as a potential effective therapeutic option for this demographic.

There are several pharmacologic agents that have been touted as guideline-directed medical therapy for heart failure with preserved ejection fraction (HFpEF). However, it is important to recognize that older adults with HFpEF also contend with an increased risk for adverse effects from medications due to age-related changes in pharmacokinetics and pharmacodynamics of medications, as well as the concurrence of geriatric conditions such as polypharmacy and frailty. With this review, we discuss the underlying evidence for the benefits of various treatments in HFpEF and incorporate key considerations for older adults, a subpopulation that may be at higher risk for adverse drug events. Key considerations for older adults include: the use of loop diuretics, mineralocorticoid receptor antagonists (MRAs), and sodium glucose co-transporter-2 (SGLT2) inhibitors for most; angiotensin receptor blockers/ angiotensin receptor-neprilysin inhibitors (ARB/ARNIs) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) as add-on therapies for some, though risk of geriatric conditions such as falls, malnutrition, and/or sarcopenia must be considered; and beta blockers for a smaller subset of patients (with consideration of deprescribing for some, though data are lacking on this approach). Naturally, when making clinical decisions for older adults with cardiovascular disease, it is critical to consider the complexity of their conditions, including cognitive and physical function and social and environmental factors, and ensure alignment of care plans with the patient's health goals and priorities.

Quetiapine is a Food and Drug Administration (FDA) approved second-generation antipsychotic. It is also commonly used at low dose for its sedative properties to treat insomnia in the older population. Quetiapine at standard doses has been associated with increased risk of cerebrovascular events, cognitive decline, and mortality in patients with dementia, especially within older adults. However, there are limited data describing its safety at lower doses, especially for the treatment of insomnia in older adults. This study aims to compare the safety of low-dose quetiapine versus trazodone or mirtazapine for insomnia in older adults in the USA. This was a retrospective cohort study that included patients aged 65 years or older who started low-dose quetiapine, trazodone, or mirtazapine for the treatment of insomnia from October 2018 to September 2021. The primary outcome was all-cause mortality and secondary outcomes included new incidences of stroke or transient ischemic attack, dementia, and falls with or without traumatic fractures. They were identified from electronic medical records using ICD-10-CM clinical diagnosis codes. Eligible patients were followed from the initiation of the drug until death, end of target drug exposure or escalation of dose, end of health plan membership, or 30 September 30 2022, whichever came first. Patients initiated mirtazapine or trazodone were matched to each patient who initiated quetiapine at a 4:1 ratio using propensity score matching method. We included 375 patients initiated on low-dose quetiapine, who were matched to 1500 patients started on trazodone and 1500 patients started on mirtazapine. Comparing patients who received quetiapine with trazodone, the quetiapine group had an increased risk of mortality (hazard ratio (HR) 3.1, 95% confidence interval (CI) 1.2-8.1; P < 0.05), dementia (HR 8.1, 95% CI 4.1-15.8; P < 0.05), and falls (HR 2.8, 95% CI 1.4-5.3; P < 0.05). When comparing quetiapine with mirtazapine, quetiapine group had an increased risk of dementia (HR 7.1, 95% CI 3.5-14.4; P < 0.05). No significant differences were detected in other outcomes. Caution should be taken in practice when using low-dose quetiapine for insomnia in older adults. It is associated with significantly higher rates of mortality, dementia, and falls when compared with trazodone and a higher dementia rate when compared with mirtazapine.

BackgroundPrescribing cascades occur when a new drug is prescribed to treat an adverse drug event caused by an existing medication, resulting in unnecessary, or potentially hazardous additional drugs. To date, there are no published studies assessing the prevalence of prescribing cascades in older hospitalised adults.ObjectiveTo investigate the prevalence of prescribing cascades in hospitalised older adults.MethodsWe conducted a prospective observational study of adults aged ≥ 65 years with multimorbidity and polypharmacy presenting to hospital with acute unselected medical or surgical illness. Prescribing cascades were identified using two predefined validated explicit cascade lists, i.e. ThinkCascades, and a list derived from a recently published systematic review of prescribing cascades in community-dwelling adults, referred to here as the ‘Doherty list’. Potential prescribing cascades were classified as ‘definite’, ‘probable’, ‘possible’, ‘uncertain’ or ‘indeterminate’ according to pre-specified criteria.ResultsThe study included 385 consecutive patients (55.1% female, mean age 80.2 years, standard deviation 7.3 years). A total of 281 potential prescribing cascades (drug A → drug B) were identified in 152 patients (39.4%). Probable or possible prescribing cascades were identified in 48 patients (12.4%) using the Doherty list and in 44 patients (11.4%) using ThinkCascades. Patients exposed to potential prescribing cascades experienced greater levels of polypharmacy than patients not exposed to prescribing cascades (median interquartile range [IQR] of 12 [9–14] daily drugs versus 9 [IQR 7–11], p < 0.001).ConclusionsPotential prescribing cascades were highly prevalent in older hospitalised adults. Practical tools are needed to assist prescribers in prevention, recognition and management of inappropriate prescribing cascades.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40266-025-01201-9.