Background: This study aimed to reveal demographic data for care-dependent older adults receiving home medical care and to evaluate whether potentially inappropriate medication (PIM) prescriptions were associated with hospitalization and death. Methods: Data of healthcare and long-term care (LTC) insurance claims of older adults aged ≥65 years receiving home medical care in Kure city, Japan, in April 2017 were obtained. They included age, sex, recorded diagnosis on medical claims, level of LTC needs, and medication profile. Hospital admissions and deaths were identified between April 2017 and April 2019. Factors associated with hospitalization/death and PIM (≥1 PIM) defined by the Screening Tool of Older Persons' potentially inappropriate Prescriptions for Japanese were analyzed statistically. Results: A total of 2,052 participants (mean age 86.5±7.4 years, female 71.7%) were included. The mean number of prescribed medications was 6.6±4.3. PIM increased as LTC level became severe (8.7% for support level 1&2; 22.6% for care level 1&2; 26.0% for care level 3–5). Among PIM, H2 receptor antagonists were the most common medication (29.0%), followed by antiplatelet agents (22.6%), magnesium oxide (19.4%), non-benzodiazepine sedatives (17.7%), and benzodiazepines (16.8%). On logistic regression analysis, the number of medications, PIM, and care level 1&2 were associated with a higher likelihood of hospital admission. There was no significant correlation between each PIM and hospital admissions. Regarding death, while age was associated with a higher likelihood, female sex and severe level of disability were associated with a lower likelihood. Conclusion PIM was prevalent among homebound older adults, suggesting that careful medication review should be conducted, especially in those with disability.

Integrated Distress Activity Score (IDAS) was developed in order to evaluate both positive and negative aspects of patient’s conditions throughout hospitalization. IDAS were evaluated by nurses everyday and when patients continued to have IDAS less than or equal to zero, we used this tool for determining continuous deep sedation. From 2013-2017, 1306 patients were enrolled in the study. The average rate of continuous deep sedation in the PCU was 1.2%(16 patients). Dyspnea was the most common condition (62.5%, 10 patients), followed by delirium (37.5%, 6 patients).The average days that took to decide for sedation (from the day when IDAS was less than or equal to zero), was 3.7 days. This study suggested that IDAS could be a useful tool for determining continuous deep sedation.

Case: The patient was a man in his 40s who had undergone proctocolectomy for familial polyposis coli and extensive resection of the small intestine for removal of an intra-abdominal desmoid tumor. He presented to our hospital with abdominal pain caused by residual desmoid tumor, and diarrhea associated with the short bowel syndrome. Adequate pain control could not be achieved even with simultaneous application of 5 sheets of 100 μg/h transdermal fentanyl patches. Subsequently, the patient was treated mainly with 270 mg/day of a slow-release morphine preparation; however, the pain control remained unsatisfactory. At our hospital, the pain treatment was switched to 240 mg/day of morphine solution, which yielded prompt reduction of the pain intensity from 9/10 to 1/10 on the numerical rating scale. Discussion: Morphine is mainly absorbed from the small intestine. The initially insufficient pain control in this patient may have been attributable to the short bowel syndrome and diarrhea causing rapid excretion of the morphine before it was absorbed. Morphine solution, in contrast, starts to be absorbed approximately 10 minutes after administration, allowing adequate absorption, leading to successful pain control, even in the present patient with the short bowel syndrome.