Vue.component('poly-cns-overview', {
	template:
		'<div>' +
			'<el-row>' +
				'<h1 style="text-align: center; ">Polypharmacy: Use of Multiple CNS-Active Medications in Older Adults (POLY-CNS)</h1>' +
			'</el-row>' +
			'<el-row id="poly-cns-description" class="scrollspy">' +
				'<h2>Description</h2>' +
			'</el-row>' +
			'<el-row>' +
				'<p>The percentage of individuals &ge;65 years of age with concurrent use of &ge;3 unique central-nervous system (CNS)-active medications.</p>' +
				'<p>A lower rate indicates better performance.</p>' +
			'</el-row>' +
			'<el-row id="poly-cns-add-info" class="scrollspy">' +
				'<h2>Additional Information</h2>' +
			'</el-row>' +
			'<el-row>' +
				'<el-col :span="6">' +
					'<p><b>Intended Use</b></p>' +
				'</el-col>' +
				'<el-col :span="18">' +
					'<p>Performance measurement for health plans.</p>' +
				'</el-col>' +
			'</el-row>' +
			'<el-row>' +
				'<el-col :span="6">' +
					'<p><b>Data Sources</b></p>' +
				'</el-col>' +
				'<el-col :span="18">' +
					'<p>Prescription claims data.</p>' +
				'</el-col>' +
			'</el-row>' +
			'<el-row>' +
				'<el-col :span="6">' +
					'<p><b>Denominator</b></p>' +
				'</el-col>' +
				'<el-col :span="18">' +
					'<p>Individuals &ge;65 years of age with &ge;2 prescription claims for the same CNS-active medication on different dates of service during the measurement year.</p>' +
				'</el-col>' +
			'</el-row>' +
			'<el-row>' +
				'<el-col :span="6">' +
					'<p><b>Exclusions</b></p>' +
				'</el-col>' +
				'<el-col :span="18">' +
					'<p>Hospice and seizure disorder.</p>' +
				'</el-col>' +
			'</el-row>' +
			'<el-row>' +
				'<el-col :span="6">' +
					'<p><b>Numerator</b></p>' +
				'</el-col>' +
				'<el-col :span="18">' +
					'<p>Individuals from the denominator with concurrent use for &ge;30 cumulative days of &ge;3 unique CNS-active medications, each with &ge;2 prescription claims on different dates of service during the measurement year.</p>' +
				'</el-col>' +
			'</el-row>' +
		'</div>'
});

Vue.component('poly-cns-ref-1', {
  template: 
    '<el-popover placement="top-start" width="400" trigger="hover">' +
      '<span>American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015; 63(11):2227-46. PMID: <a href="https://www.ncbi.nlm.nih.gov/pubmed/26446832" target="_blank">26446832</a>.</span>' +
      '<sup slot="reference">1</sup>' +
    '</el-popover>'
});

Vue.component('poly-cns-ref-2', {
  template: 
    '<el-popover placement="top-start" width="400" trigger="hover">' +
      '<span>Nurminen J, Puustinen J, Piirtola M, et al. Opioids, antiepileptic and anticholinergic drugs and the risk of fractures in patients 65 years of age and older: a prospective population-based study. Age Ageing. 2013; 42(3):318-24. PMID: <a href="https://www.ncbi.nlm.nih.gov/pubmed/23204431" target="_blank">23204431</a>.</span>' +
      '<sup slot="reference">2</sup>' +
    '</el-popover>'
});

Vue.component('poly-cns-ref-3', {
  template: 
    '<el-popover placement="top-start" width="400" trigger="hover">' +
      '<span>Weiner DK, Hanlon JT, Studenski SA. Effects of central nervous system polypharmacy on falls liability in community-dwelling elderly. Gerontology. 1998; 44(4):217-21. PMID: <a href="https://www.ncbi.nlm.nih.gov/pubmed/9657082" target="_blank">9657082</a>.</span>' +
      '<sup slot="reference">3</sup>' +
    '</el-popover>'
});

Vue.component('poly-cns-ref-4', {
  template: 
    '<el-popover placement="top-start" width="400" trigger="hover">' +
      '<span>Hanlon JT, Boudreau RM, Roumani YF, et al. Number and dosage of central nervous system medications on recurrent falls in community elders: the Health, Aging and Body Composition study. J Gerontol A Biol Sci Med Sci. 2009; 64(4):492-8. PMID: <a href="https://www.ncbi.nlm.nih.gov/pubmed/19196642" target="_blank">19196642</a>.</span>' +
      '<sup slot="reference">4</sup>' +
    '</el-popover>'
});

Vue.component('poly-cns-ref-5', {
  template: 
    '<el-popover placement="top-start" width="400" trigger="hover">' +
      '<span>Zint K, Haefeli WE, Glynn RJ, et al. Impact of drug interactions, dosage, and duration of therapy on the risk of hip fracture associated with benzodiazepine use in older adults. Pharmacoepidemiol Drug Saf. 2010; 19(12):1248-55. PubMed PMID: <a href="https://www.ncbi.nlm.nih.gov/pubmed/20931664" target="_blank">20931664</a></span>' +
      '<sup slot="reference">5</sup>' +
    '</el-popover>'
});

Vue.component('poly-cns-ref-6', {
  template: 
    '<el-popover placement="top-start" width="400" trigger="hover">' +
      '<span>Maust DT, Gerlach LB, Gibson A, et al. Trends in Central Nervous System-Active Polypharmacy Among Older Adults Seen in Outpatient Care in the United States. JAMA Intern Med. 2017; 177(4):583-585. PMID: <a href="https://www.ncbi.nlm.nih.gov/pubmed/28192559" target="_blank">28192559</a>.</span>' +
      '<sup slot="reference">6</sup>' +
    '</el-popover>'
});

Vue.component('poly-cns-ref-7', {
  template: 
    '<el-popover placement="top-start" width="400" trigger="hover">' +
      '<span>National Kidney Foundation. KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 Update. Am J Kidney Dis. 2012; 60(5):850-86. PMID: <a href="https://www.ncbi.nlm.nih.gov/pubmed/23067652" target="_blank">23067652</a>.</span>' +
      '<sup slot="reference">7</sup>' +
    '</el-popover>'
});

Vue.component('poly-cns-ref-8', {
  template: 
    '<el-popover placement="top-start" width="400" trigger="hover">' +
      '<span>Kutner JS, Blatchford PJ, Taylor DH Jr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med. 2015; 175(5):691-700. PMID: <a href="https://www.ncbi.nlm.nih.gov/pubmed/25798575" target="_blank">25798575</a>.</span>' +
      '<sup slot="reference">8</sup>' +
    '</el-popover>'
});

Vue.component('poly-cns-ref-a', {
  template: 
    '<el-popover placement="top-start" width="400" trigger="hover">' +
      '<span>Central nervous system (CNS)-active drugs: antipsychotics; benzodiazepines; nonbenzodiazepine, benzodiazepine receptor agonist hypnotics; tricyclic antidepressants (TCAs); selective serotonin reuptake inhibitors (SSRIs); and opioids. </span>' +
      '<sup slot="reference">a</sup>' +
    '</el-popover>'
});

Vue.component('poly-cns-rationale', {
	template: 
		'<div>' +
			'<el-row id="poly-cns-rationale" class="scrollspy">' +
				'<h2>Rationale</h2>' +
			'</el-row>' +
			'<el-row>' +
				'<p>The American Geriatrics Society 2015 Updated Beers Criteria provides strong recommendations based on moderate evidence to avoid concurrent use of three or more CNS-active agents in older adults because of an increased risk of falls, and for some CNS-active combinations, fractures (see Appendix for Evidence Table).' +
				'<poly-cns-ref-1></poly-cns-ref-1>' +
				' CNS-active medications are defined as: antipsychotics; antidepressants (i.e. selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants); benzodiazepines and nonbenzodiazepine sedative/hypnotics; and opioid analgesics. Multiple studies of older adults have reported that the use of CNS-active medications is linked to an increased risk of fractures, falls, and recurrent falls.' +
				'<poly-cns-ref-2></poly-cns-ref-2><sup>,</sup><poly-cns-ref-3></poly-cns-ref-3><sup>,</sup><poly-cns-ref-4></poly-cns-ref-4><sup>,</sup><poly-cns-ref-5></poly-cns-ref-5>' +
				' Specifically, older adults taking one or more CNS-active medications were at a 1.5-fold increased risk and those taking two or more CNS-active medications were at a 2.5-fold increased risk of falling compared to a reference group of no CNS-active medications. This suggests that a dose-response relationship exists between CNS-active medications and falls.' + 
				'<poly-cns-ref-3></poly-cns-ref-3>' +
				' A longitudinal cohort study performed in older adults found that in those taking higher doses of CNS-active medications had a threefold increased risk of recurrent falls.' +
				'<poly-cns-ref-4></poly-cns-ref-4>' +
				' Lastly, a recent analysis showed that CNS polypharmacy in older adults has been trending upward.' +
				'<poly-cns-ref-6></poly-cns-ref-6>' +
				' The frequency of three or more CNS-active medications being initiated or continued in older adults during a physician office visit more than doubled from 2004 to 2013. In particular, nearly half (46%) of CNS polypharmacy visits for older adults in 2013 were for individuals without pain, insomnia, or other mental health diagnoses.</p>' +
				'<p>This measure was designed for monitoring and improving quality of care across populations of patients. Medication combinations in this measure are those for which serious adverse effects have been reported among older adults. Therefore, co-prescription of the selected combinations has an unfavorable balance of benefits and harms for many, if not most, older adults. Although the combinations should be avoided in older adults, there are older adults for whom concurrent use of multiple CNS-active medications may be appropriate. Thus, the combinations are a potential serious safety concern (i.e., potentially inappropriate) and merit special scrutiny, but are not universally unsafe or inappropriate in all older adults.</p>' +
			'</el-row>' +
			'<el-row>' +
				'<p><strong>Polypharmacy: Use of Multiple CNS-Active Agents in Older Adults: Evidence Table - From the American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (Table 5, p15)<poly-cns-ref-1></poly-cns-ref-1></strong></p>' +
				'<table>' +
					'<tr><th>Target Class</th><th>Interacting Class</th><th>Risk Rationale</th><th>Recommendation</th><th>Quality of Evidence</th><th>Strength of Recommendation</th><th>Evidence</th></tr>' +
					'<tr><td>Antidepressants (i.e., TCAs and SSRIs)</td><td>&ge;2 other CNS-active drugs<poly-cns-ref-a></poly-cns-ref-a></td><td>Increased risk of falls</td><td>Avoid total of &ge;3 CNS-active drugs<poly-cns-ref-a></poly-cns-ref-a>; minimize number of CNS-active drugs</td><td>Moderate</td><td>Strong</td><td>Weiner, 1998<poly-cns-ref-3></poly-cns-ref-3> Hanlon, 2009<poly-cns-ref-4></poly-cns-ref-4></td></tr>' +
					'<tr><td>Antipsychotics</td><td>&ge;2 other CNS- active drugs<poly-cns-ref-a></poly-cns-ref-a></td><td>Increased risk of falls</td><td>Avoid total of &ge;3 CNS-active drugsa; minimize number of CNS-active drugs</td><td>Moderate</td><td>Strong</td><td>Weiner, 1998<poly-cns-ref-3></poly-cns-ref-3> Hanlon, 2009<poly-cns-ref-4></poly-cns-ref-4></td></tr>' +
					'<tr><td>Benzodiazepines and non-benzodiazepine, benzodiazepine receptor agonist hypnotics</td><td>&ge;2 other CNS-active drugs<poly-cns-ref-a></poly-cns-ref-a></td><td>Increased risk of falls and fractures</td><td>Avoid total of &ge;3 CNS-active drugs<poly-cns-ref-a></poly-cns-ref-a>; minimize number of CNS-active drugs</td><td>High</td><td>Strong</td><td>Weiner, 1998<poly-cns-ref-3></poly-cns-ref-3> Hanlon, 2009<poly-cns-ref-4></poly-cns-ref-4> Zint, 2010<poly-cns-ref-5></poly-cns-ref-5></td></tr>' +				
					'<tr><td>Opioid receptor agonist analgesics</td><td>&ge;2 other CNS-active drugs<poly-cns-ref-a></poly-cns-ref-a></td><td>Increased risk of falls</td><td>Avoid total of &ge;3 CNS-active drugs<poly-cns-ref-a></poly-cns-ref-a>; minimize number of CNS-active drugs</td><td>High</td><td>Strong</td><td>Weiner, 1998<poly-cns-ref-3></poly-cns-ref-3> Hanlon, 2009<poly-cns-ref-4></poly-cns-ref-4> Nurminen, 2013<poly-cns-ref-2></poly-cns-ref-2></td></tr>' +
				'</table>' +
			'</el-row>' +
		'</div>'
});

Vue.component('poly-cns', {
	template:
		'<div id="poly-cns" class="search-filter inview">' +
			'<poly-cns-overview></poly-cns-overview>' +
            '<poly-cns-rationale v-if="rationale"></poly-cns-rationale>' +
			'<br><br><br><br>' +
		'</div>',
	props: {
		rationale: {
			default: false
		},
		faqs: {
			default: false
		}
	}
});