The American Journal Of Geriatric Pharmacotherapy[JOURNAL]
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200 papers
Atypical antipsychotic use and parkinsonism in dementia: effects of drug, dose, and sex.
Marras C, Herrmann N, Anderson GM … +3 more , Fischer HD, Wang X, Rochon PA
Am J Geriatr Pharmacother · 2012 Dec · PMID 23217531 · Publisher ↗
BACKGROUND: Differences between atypical antipsychotics in their potential to cause parkinsonism and risk factors for antipsychotic-induced parkinsonism are not well established. There is a particular paucity of informat...
BACKGROUND: Differences between atypical antipsychotics in their potential to cause parkinsonism and risk factors for antipsychotic-induced parkinsonism are not well established. There is a particular paucity of information on this in real-world use of these drugs, outside of clinical trial settings. OBJECTIVE: We compared the incidence of parkinsonism after new treatment with risperidone, olanzapine, or quetiapine in patients with dementia and examined the effects of dose and sex on the risk of parkinsonism. METHODS: Administrative data from Ontario, Canada between 2002 and 2010 were used to compare the incidence of a diagnostic code for parkinsonism or prescription of an anti-Parkinson medication among patients with dementia who were newly prescribed quetiapine, olanzapine, or risperidone. RESULTS: From 15,939 person-years of observation, 421 patients developed parkinsonism. Using low-dose risperidone as the reference group, the adjusted hazard ratios for developing parkinsonism were 0.49 (95% CI, 0.07-3.53) for low-dose olanzapine and 1.18 (95% CI, 0.84-1.66) for low-dose quetiapine. Comparing across drugs within the most commonly prescribed dose ranges, the incidence of parkinsonism was higher in the medium-dose olanzapine group compared with the low-dose risperidone group (hazard ratio 1.66; 95% CI 23-2.23). The adjusted hazard ratio for developing parkinsonism for men (compared with women) was 2.29 (95% CI, 1.88- 2.79). CONCLUSIONS: We found no evidence that the risk of drug-induced parkinsonism in older adults with dementia was different among quetiapine, olanzapine, or risperidone, challenging the notion that the drugs differed in their propensity to cause parkinsonism. Men appeared to be at higher risk of parkinsonism as a adverse event than women.
Use of rivastigmine or galantamine and risk of adverse cardiac events: a database study from the Netherlands.
Kröger E, Berkers M, Carmichael PH … +3 more , Souverein P, van Marum R, Egberts T
Am J Geriatr Pharmacother · 2012 Dec · PMID 23217530 · Publisher ↗
BACKGROUND: Two cholinesterase inhibitors (ChEIs), rivastigmine and galantamine, are used to treat Alzheimer disease in the Netherlands. Several adverse cardiac events have been reported for these medications. OBJECTIVE:...
BACKGROUND: Two cholinesterase inhibitors (ChEIs), rivastigmine and galantamine, are used to treat Alzheimer disease in the Netherlands. Several adverse cardiac events have been reported for these medications. OBJECTIVE: We aimed to assess if the use of ChEIs increased the risk of cardiac events in the Netherlands. METHODS: A cohort crossover study of the PHARMO Record Linking System database included patients who initiated ChEIs at age 50 years or older, had at least 1 dispensing of a ChEI drug between 1998 and 2008, a 1-year history in PHARMO, and 1 subsequent dispensing of any medication. Two outcomes were assessed: a first hospitalization for syncope or atrioventricular block. Poisson and Cox regression were used to calculate incidence densities and hazard ratios for cardiac events during periods with ChEI use, compared with periods without ChEI use. RESULTS: During the complete observation period of 8.9 years (interquartile range 6.7 to 10.2) there were 132 first hospitalizations for atrioventricular block and 17 first hospitalizations for syncope among 3358 patients. The adjusted incidence densities were significantly increased during ChEI exposure for syncope and atrioventricular block, when compared with the background incidence densities in the roughly 5 years before the last year before ChEI initiation. However, when exposed periods were compared with the unexposed periods 1 year before ChEI initiation and times after exposure, the adjusted hazard ratios remained increased for syncope and atrioventricular block, but increases were not significant anymore. CONCLUSIONS: Exposure to ChEIs might increase the risk of adverse cardiac events, but small numbers of cases limit conclusions about the risk in this population and research on larger study samples is needed.
Use of warfarin therapy among residents who developed venous thromboembolism in the nursing home.
Reardon G, Pandya N, Nutescu EA … +4 more , Lamori J, Damaraju CV, Schein J, Bookhart BK
Am J Geriatr Pharmacother · 2012 Dec · PMID 23217529 · Publisher ↗
BACKGROUND: Treatment of venous thromboembolism (VTE) in long-term care (LTC) settings has received little empirical study. OBJECTIVE: Among residents with VTE in nursing homes, this analysis evaluated frequency of antic...
BACKGROUND: Treatment of venous thromboembolism (VTE) in long-term care (LTC) settings has received little empirical study. OBJECTIVE: Among residents with VTE in nursing homes, this analysis evaluated frequency of anticoagulant use, the proportion of residents newly started on warfarin who persisted on therapy (≥3 months), and the association of key resident characteristics, including bleeding risk, with warfarin use and persistence. METHODS: Using the AnalytiCare LTC database (US), eligible residents had deep vein thrombosis or pulmonary embolism coded in the Minimum Data Set (MDS) 2.0 during the uptake period April 1, 2007 through December 31, 2008 (earliest VTE was index date) and had 1 or more MDS assessment(s) over the 90-day preindex period, each negative for VTE. Logistic regression evaluated the association of resident characteristics with warfarin use. Cox regression evaluated persistence with warfarin therapy. RESULTS: The median age of residents with VTE included in the analysis (N = 489) was 80 years; 73% received anticoagulant therapy and 66% were prescribed warfarin ±45 days of the index date. Multivariate logistic regression identified several factors significantly associated with warfarin use: location in South Central region (odds ratio [OR] = 1.94, P = 0.019) and the Western region (OR = 2.53, P = 0.005) [both vs reference South Atlantic]; body mass index categories normal (OR = 2.73, P = 0.045), overweight (OR = 4.21, P = 0.005), and obese (OR = 3.82, P = 0.010) (both vs reference underweight); Alzheimer's/dementia (OR = 0.52, P = 0.024); cancer (OR = 0.39, P = 0.008); and moderate-dependent versus independent physical functioning (OR = 2.59, P = 0.003). Of residents newly started on warfarin therapy with no history of cancer (n = 149), 28% discontinued warfarin within 90 days of initiation. Peripheral vascular disease (PVD) (OR = 4.07, P < 0.001), Alzheimer's disease/dementia (OR = 2.55, P = 0.046), and antipsychotic use (OR = 4.60, P < 0.001) were all significantly associated with discontinuation. CONCLUSIONS: Patients in specific geographic regions who were underweight, had Alzheimer's disease/dementia or cancer, or had independent physical functioning were less likely to receive warfarin. Nonpersistence of warfarin therapy was strongly related to antipsychotic use, presence of dementia, or PVD.
Warfarin-antibiotic interactions in older adults of an outpatient anticoagulation clinic.
Ghaswalla PK, Harpe SE, Tassone D … +1 more , Slattum PW
Am J Geriatr Pharmacother · 2012 Dec · PMID 23089199 · Publisher ↗
BACKGROUND: Several classes of drugs, such as antibiotics, may interact with warfarin to cause an increase in warfarins anticoagulant activity and the clinical relevance of warfarin-antibiotic interactions in older adult...
BACKGROUND: Several classes of drugs, such as antibiotics, may interact with warfarin to cause an increase in warfarins anticoagulant activity and the clinical relevance of warfarin-antibiotic interactions in older adults is not clear. OBJECTIVE: The aim of this study was to determine the effect of oral antibiotics, such as amoxicillin, azithromycin, cephalexin, ciprofloxacin, levofloxacin, and moxifloxacin, on the international normalized ratio (INR) in patients ≥65 years on stable warfarin therapy. The secondary objective was to compare the effect of warfarin-antibiotic interactions on outcomes of overanticoagulation. METHODS: Data for this retrospective cohort study were collected through a medical record review of patients in an outpatient anticoagulation clinic of a Veterans Affairs medical center. Patients aged ≥65 years on stable warfarin therapy and with at least 1 prescription of an oral antibiotic of interest during the period from January 1, 2003 to March 1, 2011 were included. A mixed-effects repeated-measures ANOVA model was used to determine the effect of antibiotics on the mean change in patients' INR. The Fisher exact test was used to determine the association between the antibiotics and secondary outcomes of overanticoagulation, using cephalexin as the control. Statistical significance was defined as a P value <0.05. RESULTS: A total of 205 patients had 364 prescriptions for warfarin and antibiotics concomitantly, and there was a significant interaction between antibiotic and time (F(15, 358) = 1.9; P = 0.0221). Antibiotics with a significant increase in INR were amoxicillin (P = 0.0019), azithromycin (P < 0.0001), ciprofloxacin (P = 0.002), levofloxacin (P < 0.0001) and moxifloxacin (P < 0.0001). There was a significant association between type of antibiotic and secondary outcomes of overanticoagulation. CONCLUSIONS: In older patients on stable warfarin therapy, antibiotics may lead to an increase in INR. However, this may not result in clinically significant outcomes of bleeding or hospitalization, suggesting that antibiotics may be prescribed for older adults taking warfarin as long as their INR is being routinely monitored.
Effect of combination fluticasone propionate and salmeterol or inhaled corticosteroids on asthma-related outcomes in a Medicare-eligible population.
Stanford RH, Blanchette CM, Roberts MH … +2 more , Petersen H, Fuhlbrigge AL
Am J Geriatr Pharmacother · 2012 Dec · PMID 23083688 · Publisher ↗
BACKGROUND: National asthma treatment guidelines recommend either the use of inhaled corticosteroids (ICS) or ICS in combination with a long-acting bronchodilator for the treatment of moderate to severe asthma. Even thou...
BACKGROUND: National asthma treatment guidelines recommend either the use of inhaled corticosteroids (ICS) or ICS in combination with a long-acting bronchodilator for the treatment of moderate to severe asthma. Even though asthma is common among older adults, few studies have assessed the differences in effectiveness between these two recommended therapies in patients over 65 years of age. OBJECTIVE: The aim of this study was to assess the association of the fluticasone-salmeterol combination (FSC) or ICS initiation on asthma-related events in Medicare-eligible asthma patients. METHODS: This was a retrospective observational study using a large health claims database (July 1, 2001 to June 30, 2008). Subjects 65 to 79 years of age with 12-month preindex and 3- to 12-month postindex eligibility, an asthma diagnosis (ICD-493.xx), and with 1 or more FSC or ICS claims at index were included. Subjects with an FSC or ICS claim in the preindex and any claim for chronic obstructive pulmonary disease were excluded. Subjects were observed until they had an event (emergency department [ED] inpatient hospitalization [IP], combined IP/ED or oral corticosteroid [OCS] use) or were no longer eligible in the database, whichever came first. Cox proportional hazards regression was used to assess risk of an asthma-related event (IP, ED, or IP/ED). Baseline characteristics (age, sex, region, index season, comorbidities, preindex use of short-acting β-agonists, OCS, other asthma controllers, and asthma-related ED/IP visits) were independent covariates in the model. RESULTS: A total of 10,837 met the criteria (4843 ICS and 5994 FSC). Age (70.4 and 70.5 years, respectively) and the percentage of female subjects (65.5% and 64.8%, respectively) were similar. Asthma-related events were also similar at baseline. Postindex unadjusted rates occurring after >30 days were ED (1.8% vs 1.5%, P = 0.18), IP (2.7% vs 1.7%, P < 0.001), and ED/IP (4.1% vs 2.8%, P < 0.001) for ICS and FSC, respectively. Subjects who received FSC were associated with a 32% (adjusted HR = 0.68; 95% CI, 0.51-0.91) lower risk of experiencing an IP visit and a 22% (HR = 0.78; 95% CI, 0.62-0.98) lower risk of experiencing an ED/IP visit. No differences were observed for ED visits (HR = 0.94; 95% CI, 0.68-1.29). CONCLUSIONS: In Medicare-eligible asthma patients, FSC use was associated with lower rates of asthma-related serious exacerbations compared with ICS.
Dementia and risk of adverse warfarin-related events in the nursing home setting.
Tjia J, Field TS, Mazor KM … +6 more , Donovan JL, Kanaan AO, Reed G, Doherty P, Harrold LR, Gurwitz JH
Am J Geriatr Pharmacother · 2012 Oct · PMID 23063288 · Publisher ↗
BACKGROUND: Little attention has been focused on the safety of medications administered to treat non illnesses in nursing home residents with dementia. It is unclear whether this population is at increased risk of advers...
BACKGROUND: Little attention has been focused on the safety of medications administered to treat non illnesses in nursing home residents with dementia. It is unclear whether this population is at increased risk of adverse drug events. OBJECTIVES: To test the hypotheses that in nursing home residents with dementia prescribed warfarin have less time in therapeutic range and a higher incidence of nonpreventable and preventable adverse warfarin events compared to nursing home residents without dementia after controlling for facility and patient characteristics. METHODS: A prospective cohort embedded in a clinical trial of nursing home residents prescribed warfarin in 26 nursing homes in Connecticut was observed for up to 12 months. The primary outcome measures included adverse warfarin events (AWEs) (injuries resulting from warfarin use), potential AWEs (INR [international normalized ratio] >4.5 and management error), and AWE preventability based on physician reviews of medical record abstractions. Potential confounders included nursing home structural characteristics (eg, number of beds and for-profit status), nursing staff time, and nursing home regulatory deficiencies (pharmacy, administrative, quality of care, and all other deficiencies). Multivariable Poisson regression analysis was used to determine the independent association of dementia with potential and preventable AWEs using generalized estimating equations to account for clustering within nursing homes. RESULTS: Residents with dementia had no difference in the number of INR monitoring tests or percentage of days in the therapeutic range, but did have an increased risk of AWEs (adjusted incidence rate ratio [IRR], 1.47; 95% confidence interval [CI], 1.20-1.82), and preventable or potential AWEs (adjusted IRR, 1.36; 95% CI, 1.06-1.76) after adjustment for patient characteristics, nursing home quality, and case mix. Greater nursing staff time was protective for preventable and potential AWEs (adjusted IRR, 0.66; 95% CI, 0.48-0.90) but not for nonpreventable AWEs. CONCLUSION: A diagnosis of dementia was associated with increased risk of nonpreventable and preventable or potential AWEs. Greater nursing staff time was associated with lower risk of preventable AWEs. These findings have implications for quality-of-care reporting and patient safety.
The effect of statins on acute and long-term outcome after ischemic stroke in the elderly.
Hjalmarsson C, Bokemark L, Manhem K … +2 more , Mehlig K, Andersson B
Am J Geriatr Pharmacother · 2012 Oct · PMID 23063287 · Publisher ↗
BACKGROUND: Although treatment with statins has produced beneficial effects when used as secondary prevention, its primary protective role is still somewhat controversial. Moreover, few studies have evaluated the effect...
BACKGROUND: Although treatment with statins has produced beneficial effects when used as secondary prevention, its primary protective role is still somewhat controversial. Moreover, few studies have evaluated the effect of statins in older patients with stroke. OBJECTIVE: The aim was to investigate whether treatment with statins decreases stroke severity and/or improves survival and outcome after stroke in an older population. METHODS: We investigated the association between previous statin use and stroke severity (National Institutes of Health Stroke Scale [NIHSS]), as well as the effect of poststroke statin treatment on 12-month functional outcome (modified Rankin Scale [mRS] score) in 799 patients (mean age, 78 years), with acute ischemic stroke. The effect of statin treatment on survival was examined using the Cox proportional hazard model, after adjusting for relevant covariates. RESULTS: Statins did not decrease stroke severity and did not improve 30-day survival. However, both the 12-month survival (hazard ratio = 0.33; 95% CI, 0.20-to 0.54; P < 0.001) and the 12-month functional outcome (odds ratio = 2.09; 95% CI, 1.25-3.52; P = 0.005) were significantly better in the group treated with statins. CONCLUSIONS: Significantly better survival and functional outcome were noted with poststroke statins at the end of the 12-month follow-up period. Statins seem to provide beneficial effects for the long-term functional outcome and survival in the elderly.
Racial and ethnic disparities in Alzheimer's disease pharmacotherapy exposure: an analysis across four state Medicaid populations.
Gilligan AM, Malone DC, Warholak TL … +1 more , Armstrong EP
Am J Geriatr Pharmacother · 2012 Oct · PMID 23063286 · Publisher ↗
BACKGROUND: Treatment disparities in Alzheimer's disease (AD) have received little attention. Determining whether disparities exist in this subpopulation is an important health policy issue. OBJECTIVE: The aim was to det...
BACKGROUND: Treatment disparities in Alzheimer's disease (AD) have received little attention. Determining whether disparities exist in this subpopulation is an important health policy issue. OBJECTIVE: The aim was to determine whether an association existed between race/ethnicity and exposure to AD pharmacotherapy across 4 state Medicaid populations. METHODS: Data from the Centers for Medicare and Medicaid Services (CMS) were used in this retrospective study. Persons with AD enrolled in California, Florida, New Jersey, or New York Medicaid programs on January 1, 2004, and remained in that program for 1 year. Individuals had an AD diagnosis based on the ICD-9-CM code 331.0. Outcomes of interest were exposure to a cholinesterase inhibitor (ChEI) or memantine. Multivariate logistic regression was used to test for the association between race/ethnicity and exposure to a ChEI or memantine. Variables of interest included demographic characteristics and resource utilization factors. The Oaxaca-Blinder decomposition method was used to test for disparities to determine whether exposure to AD pharmacotherapy was influenced by race. RESULTS: Race, age, long-term care admittance, inpatient care admittance, state of residence, and sex were significant predictors of AD pharmacotherapy exposure (P < 0.0001 for all variables). Racial/ethnic disparities were observed with respect to exposure to a ChEI or memantine between non-Hispanic whites and Hispanics (in favor of Hispanics) in Florida (P < 0.0001), between non-Hispanic blacks and Hispanics (in favor of Hispanics) in California (P < 0.0001) and Florida (P < 0.0001), between non-Hispanic blacks and non-Hispanic others (in favor of non-Hispanic others) in California (P < 0.0001) and New York (P < 0.0001), and between Hispanics and non-Hispanic others (in favor of non-Hispanic others) in California (P = 0.001) and New York (P < 0.0001). CONCLUSIONS: Disparities in AD pharmacotherapy exposure among minority populations are just as prevalent, if not of greater magnitude, than minority/white disparities.
Adverse effects of analgesics commonly used by older adults with osteoarthritis: focus on non-opioid and opioid analgesics.
O'Neil CK, Hanlon JT, Marcum ZA
Am J Geriatr Pharmacother · 2012 Dec · PMID 23036838 · Full text
BACKGROUND: Osteoarthritis (OA) is the most common cause of disability in older adults, and although analgesic use can be helpful, it can also result in adverse drug events. OBJECTIVE: To review the recent literature to...
BACKGROUND: Osteoarthritis (OA) is the most common cause of disability in older adults, and although analgesic use can be helpful, it can also result in adverse drug events. OBJECTIVE: To review the recent literature to describe potential adverse drug events associated with analgesics commonly used by older adults with OA. METHODS: To identify articles for this review, a systematic search of the English-language literature from January 2001 to June 2012 was conducted using PubMed, MEDLINE, EBSCO, and the Cochrane Database of Systematic Reviews for publications related to the medical management of OA. Search terms used were "analgesics," "acetaminophen," "nonsteroidal anti-inflammatory drugs" (NSAIDs), "opioids," "pharmacokinetics," "pharmacodynamics," and "adverse drug events." The search was restricted to those articles that concerned humans aged ≥65 years. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that examined analgesic use in older adults. RESULTS: There are limited data to suggest that non-frail elders are more likely than their younger counterparts to develop acetaminophen-induced hepatotoxicity. However, decreased hepatic phase II metabolism in frail elders may result in increased risk of hepatotoxicity. It is now well established that older adults are at higher risk of NSAID-induced gastrointestinal toxicity and renal insufficiency. Insofar as opioids, the data that suggest an increased risk of falls, fractures, or delirium need to be tempered by the potential risk of inadequately treating severe chronic OA-related pain. CONCLUSIONS: Acetaminophen is the mainstay frontline analgesic for treating OA-related pain in older adults. NSAIDs should be limited to short-term use only, and for moderate to severe OA-related pain, opioids may be preferable in individuals without substance abuse or dependence issues.
Caregiver assistance among Medicare beneficiaries with atrial fibrillation and factors associated with anticoagulant treatment.
Chen SY, Vanderpoel J, Mody S … +4 more , Nelson WW, Schein J, Rao P, Boulanger L
Am J Geriatr Pharmacother · 2012 Oct · PMID 22981404 · Publisher ↗
BACKGROUND: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and disproportionately affects the elderly. OBJECTIVE: This study describes patient characteristics and caregiver assistance among Medi...
BACKGROUND: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and disproportionately affects the elderly. OBJECTIVE: This study describes patient characteristics and caregiver assistance among Medicare beneficiaries with AF and examines factors associated with receiving anticoagulant treatment. METHODS: Patients with AF and age/gender-matched controls were identified from Medicare Current Beneficiary Survey data from 2001 to 2006. A logistic regression model was used to assess factors associated with receiving anticoagulants in a subgroup of patients with AF whose treatment pattern was established for 2 consecutive years. Sample weights were applied to obtain nationally representative estimates. RESULTS: A total of 2990 patients with AF and 5980 control patients were included in the burden of disease analysis, and 1481 patients with AF were included in the anticoagulant predictor analysis. Patients with AF had a higher level of comorbidity (Charlson Comorbidity Index: 3.3 vs 1.5; P < 0.05), worse self-perceived health status (P < 0.001), and greater level of disability (P < 0.001) than their matched counterparts. A greater proportion of patients with AF required caregiver assistance (62.8% vs 51.5%; P < 0.001). Logistic regression found that higher Charlson Comorbidity Index scores, difficulty in obtaining necessary health care, older age, being widowed, a history of psychiatric disorders, and being underweight decreased the likelihood of receiving anticoagulant therapy. CONCLUSIONS: In a Medicare population, a greater need for caregiver assistance was observed in patients with AF. Subgroups characterized by frailty or inability for self-care were identified as being less likely to receive anticoagulant therapy. The need for caregiver assistance among patients with AF, as well as the patient subgroups identified as less likely to receive anticoagulant therapy, should be considered when making treatment decisions.
Medication discrepancy and potentially inappropriate medication in older Chinese-American home-care patients after hospital discharge.
Hu SH, Capezuti E, Foust JB … +2 more , Boltz MP, Kim H
Am J Geriatr Pharmacother · 2012 Oct · PMID 22944511 · Publisher ↗
BACKGROUND: Studies of potential medication problems among older adults have focused on English-speaking populations in a single health care setting or a single potential medication problem. No previous studies investiga...
BACKGROUND: Studies of potential medication problems among older adults have focused on English-speaking populations in a single health care setting or a single potential medication problem. No previous studies investigated potential inappropriate medications (PIMs) and medication discrepancies (MDs) among older Chinese Americans during care transitions from hospital discharge to home care. OBJECTIVE: The aims of this study were to examine, in older Chinese Americans, the prevalence of both PIMs and MDs; the relationship between PIMs and MDs; and the patient and hospitalization characteristics associated with them during care transitions from hospital discharge to home care. METHODS: This cross-sectional study was conducted with a sample of older Chinese Americans from a large certified nonprofit home-care agency in New York City from June 2010 to July 2011. PIMs were identified by using 2002 diagnosis-independent Beers criteria. MDs were identified by comparing the differences between hospital discharge medication order and home-care admission medication order. Prevalence of PIMs and MDs and their relationship was determined. Logistic regression examined the relationship between hospitalization and patient characteristics with PIMs and MDs. RESULTS: The sample consisted of 82 older Chinese-American home-care patients. Twenty (24.3%) study participants were prescribed at least one PIM at hospital discharge. Fifty-one (67.1%) study participants experienced at least one MD. A positive correlation was found between the occurrence of PIMs and MDs (r = 0.22; P = 0.05). Number of medications was the only significant factor associated with both PIMs and MDs. In addition, older age and more hospitalization days were associated with PIMs. CONCLUSIONS: The evident prevalence of PIMs and MDs supports the practice of evaluating the appropriateness of medications while reconciling inconsistencies in medication regimens. The number of medications was the only factor associated with both PIMs and MDs, underscoring the need to address polypharmacy as a multifaceted threat to patient health.
The effect of HMG-CoA reductase inhibitors on cognition in patients with Alzheimer's dementia: a prospective withdrawal and rechallenge pilot study.
Padala KP, Padala PR, McNeilly DP … +3 more , Geske JA, Sullivan DH, Potter JF
Am J Geriatr Pharmacother · 2012 Oct · PMID 22921881 · Publisher ↗
BACKGROUND: Statins are well-known for their cardiovascular benefits. However, the cognitive effects of statins are not well understood. We hypothesized that individuals with preexisting dementia would be more vulnerable...
BACKGROUND: Statins are well-known for their cardiovascular benefits. However, the cognitive effects of statins are not well understood. We hypothesized that individuals with preexisting dementia would be more vulnerable to statin-related cognitive effects. OBJECTIVE: The aim of this study was to evaluate the impact on cognition of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor (statin) discontinuation and rechallenge in individuals with Alzheimer's dementia (AD) on statins at baseline. METHODS: A 12-week prospective, open-label study was conducted in a geriatric clinic setting. Eighteen older subjects underwent a 6-week withdrawal phase of statins followed by a 6-week rechallenge. The primary outcome measure was cognition, measured by the Mini-Mental State Examination (MMSE); secondary outcome measures were the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery, Activities of Daily Living (ADL) scale, Instrumental ADL (IADL) scale, and fasting cholesterol. The change in outcome measures was assessed using repeated-measures ANOVA and paired t tests. RESULTS: At the end of the intervention, there was a significant difference across time for MMSE score (P = 0.018), and total cholesterol (P = 0.0002) and a trend toward change across time for ADL (P = 0.07) and IADL (P = 0.06) scale scores. Further analyses using paired t tests indicated improvement in MMSE scores (Δ1.9 [3.0], P = 0.014) with discontinuation of statins and a decrease in MMSE scores (Δ1.9 [2.7], P = 0.007) after rechallenge. Total cholesterol increased with statin discontinuation (P = 0.0003) and decreased with rechallenge (P = 0.0007). The CERAD score did not show a change across time (P = 0.31). There was a trend toward improvement in ADL (P = 0.07) and IADL (P = 0.06) scale scores with discontinuation of statins, but no change with rechallenge. CONCLUSIONS: This pilot study found an improvement in cognition with discontinuation of statins and worsening with rechallenge. Statins may adversely affect cognition in patients with dementia.
Pharmacist- versus physician-initiated admission medication reconciliation: impact on adverse drug events.
Mergenhagen KA, Blum SS, Kugler A … +7 more , Livote EE, Nebeker JR, Ott MC, Signor D, Sung S, Yeh J, Boockvar KS
Am J Geriatr Pharmacother · 2012 Aug · PMID 22819386 · Publisher ↗
BACKGROUND: Medication reconciliation (MR) has proven to be a problematic task for many hospitals to accomplish. It is important to know the clinical impact of physician- versus pharmacist-initiated MR in the resource-li...
BACKGROUND: Medication reconciliation (MR) has proven to be a problematic task for many hospitals to accomplish. It is important to know the clinical impact of physician- versus pharmacist-initiated MR in the resource-limited hospital environment. METHODS: This quasi-experimental study took place from December 2005 to February 2006 at an urban US Veterans Affairs hospital. MR was implemented on 2 similar general medical units: one received physician-initiated MR and the other received pharmacist-initiated MR. Adverse drug events (ADEs) and a 72-hour medication-prescribing risk score were ascertained by research pharmacists for all admitted patients by structured record review. Multivariable models were tested for intervention effect, accounting for quasi-experimental design and clustered observations, and were adjusted for patient and encounter covariates. RESULTS: Pharmacists completed the MR process in 102 admissions and physicians completed the process in 116 admissions. In completing the MR process, pharmacists documented statistically more admission medication changes than physicians (3.6 vs 0.8; P < 0.001). The adjusted odds of an ADE caused by an admission prescribing change with pharmacist-initiated MR compared with a physician-initiated MR were 1.04 with a 95% CI of 0.53 to 2.0. The adjusted odds of an ADE caused by an admission prescribing change that was a prescribing error with pharmacist-initiated MR compared with a physician-initiated MR were 0.38 with a confidence interval of 0.14 to 1.05. No difference was observed in 72-hour prescribing risk score (coefficient = 0.10; 95% CI, -0.54 to 0.75). CONCLUSION: MR performed by pharmacists versus physicians was more comprehensive and was followed by lower odds of ADEs from admission prescribing errors but with similar odds of all types of ADEs. Further research is warranted to examine how MR tasks may be optimally divided among clinicians and the mechanisms by which MR affects the likelihood of subsequent ADEs.
Anticholinergic drugs and functional outcomes in older patients undergoing orthopaedic rehabilitation.
Koshoedo S, Soiza RL, Purkayastha R … +1 more , Mangoni AA
Am J Geriatr Pharmacother · 2012 Aug · PMID 22795433 · Publisher ↗
BACKGROUND: Medications with anticholinergic (antimuscarinic) effects negatively affect physical and cognitive function in community-dwelling older patients. However, it is unknown if anticholinergic drugs exert detrimen...
BACKGROUND: Medications with anticholinergic (antimuscarinic) effects negatively affect physical and cognitive function in community-dwelling older patients. However, it is unknown if anticholinergic drugs exert detrimental effects in older patients undergoing rehabilitation. OBJECTIVE: The purpose of our study was to assess the effect of anticholinergic drug exposure on functional outcomes in older patients undergoing rehabilitation. We speculated that higher anticholinergic drug exposure would be associated with reduced functional outcomes in this group. METHODS: Data on clinical characteristics, full medication, anticholinergic drug exposure (total number of anticholinergic drugs [tAD] and Anticholinergic Risk Scale [ARS] score), and Barthel index (BI) score were collected on admission and discharge in a consecutive series of 117 older patients (age 79 [7] years) admitted to the orthopaedic rehabilitation unit of a teaching hospital between July 2010 and March 2011. Outcome measures were BI changes (BI on discharge - BI on admission) during rehabilitation (primary outcome) and length of stay (secondary outcome). RESULTS: Anticholinergic drugs were prescribed in 38 patients (32.5%). Median and interquartile range for tAD = 0 (0-1); for ARS = 0 (0-1). Poisson regression showed that higher tAD (incidence rate ratio [IRR] = 0.92; 95% CI, 0.88-0.97; P = 0.003) and ARS scores (IRR = 0.97; 95% CI, 0.95-0.99; P = 0.008) on admission independently predicted lower BI changes. Being a woman (IRR = 0.87; 95% CI, 0.78-0.97; P = 0.01), lower Abbreviated Mental Test scores (IRR = 0.94; 95% CI, 0.91-0.97; P < 0.001), and lower BI on admission (IRR = 0.98; 95% CI, 0.97-0.98; P < 0.001), but not tAD or ARS scores, independently predicted increasing length of stay. CONCLUSIONS: Higher anticholinergic drug exposure on admission independently predicts reduced functional outcomes, but not length of stay, in older patients undergoing orthopaedic rehabilitation.
Looking beyond polypharmacy: quantification of medication regimen complexity in the elderly.
Mansur N, Weiss A, Beloosesky Y
Am J Geriatr Pharmacother · 2012 Aug · PMID 22749668 · Publisher ↗
BACKGROUND: Polypharmacy has been shown to influence outcomes in elderly patients. However, the impact of medication regimen complexity, quantified by the Medication Regimen Complexity Index (MRCI), on health outcomes af...
BACKGROUND: Polypharmacy has been shown to influence outcomes in elderly patients. However, the impact of medication regimen complexity, quantified by the Medication Regimen Complexity Index (MRCI), on health outcomes after discharge of elderly patients has not been studied. OBJECTIVE: Our aim was to test the convergent, discriminant, and predictive validity of the MRCI in older hospitalized patients with varying functional and cognitive levels. METHODS: We retrospectively applied the MRCI to the medication regimen of 212 hospitalized patients and assessed its validity. RESULTS: The mean (SD) MRCI scores for medication regimens and number of medications at discharge were 30.27 (13.95) and 5.95 (2.40), respectively. The MRCI scores were strongly correlated with the number of medications (r=0.94, P<0.001) and the number of daily doses (r=0.87, P<0.001) and increased as the number of medications taken ≥3 times daily increased (27.35, 34.45, and 43.00 for none, 1, and 2 drugs, respectively; P<0.001). Positive correlations were observed between the Cumulative Illness Rating Scale-Geriatrics score and both the number of medications and the MRCI score (r=0.40, r=0.46, P<0.001, respectively). No relationship was found between MRCI scores and the number of medications and age, sex, and postdischarge medication modifications. Patients nonadherent to at least 1 drug were discharged with a higher MRCI score and higher number of medications compared with medication-compliant patients (33.3 and 7.0 vs 27 and 5.8, respectively; P<0.01). An inverse correlation was found between overall adherence 1 month after discharge and the MRCI score (r=-0.188, P= 0.028); however, no such correlation was found regarding the number of medications at discharge. CONCLUSIONS: The MRCI showed satisfactory validity and good evidence of classifying regimen complexity over a simple medication count. The MRCI demonstrated application in clinical research and practice in the elderly. However, more studies are needed to investigate its advantage over the number of medications for identifying patients with complex medication regimens and directing interventions to simplify their medication regimen complexity.
The impact of family caregivers on potentially inappropriate medication use in noninstitutionalized older adults with dementia.
Thorpe JM, Thorpe CT, Kennelty KA … +2 more , Gellad WF, Schulz R
Am J Geriatr Pharmacother · 2012 Aug · PMID 22683399 · Full text
BACKGROUND: The risk of potentially inappropriate medication (PIM), both prescription and over-the-counter, use in dementia patients is high. Informal caregivers often facilitate patients' use of medications, but the eff...
BACKGROUND: The risk of potentially inappropriate medication (PIM), both prescription and over-the-counter, use in dementia patients is high. Informal caregivers often facilitate patients' use of medications, but the effect of caregiver factors on PIM use has not been a focus of previous research. OBJECTIVE: The aim of this study was to examine PIM use in dementia patients and caregivers and identify caregiver risk factors for PIM use in dementia patients. METHODS: We conducted a secondary data analysis of the baseline wave of the Resources for Enhancing Alzheimer's Caregiver's Health study. The sample comprised 566 persons with dementia aged 65 and older and their coresiding family caregiver. PIM was defined using the 2003 Beers criteria and was examined in both dementia patients and their caregivers. Caregiver and patient risk factors included a range of sociodemographic and health variables. RESULTS: In dementia patients, 33% were taking at least 1 PIM, and 39% of their caregivers were also taking a PIM. In fully adjusted models, the following caregiver factors were associated with an increased risk of dementia patient PIM use: caregiver's own PIM use, spouse caregivers, Hispanic caregivers, and greater number of years that the caregiver has lived in the United States. Increased caregiver age was associated with a decreased risk of PIM use in patients. CONCLUSIONS: PIM use may be higher in dementia patients and their informal caregivers compared with the general older adult population. Further, patterns of medication use in 1 member of the dyad may influence PIM risk in the other dyad member. These results suggest that interventions to increase appropriate medication use in dementia patients and their caregivers should target both members of the dyad and target over-the-counter agents along with prescription medications.
FDA drug safety communications: a narrative review and clinical considerations for older adults.
Marcum ZA, Vande Griend JP, Linnebur SA
Am J Geriatr Pharmacother · 2012 Aug · PMID 22683398 · Full text
BACKGROUND: The US Food and Drug Administration (FDA) has new regulatory authorities intended to enhance drug safety monitoring in the postmarketing period. This has resulted in an increase in communication from the FDA...
BACKGROUND: The US Food and Drug Administration (FDA) has new regulatory authorities intended to enhance drug safety monitoring in the postmarketing period. This has resulted in an increase in communication from the FDA in recent years about the safety profile of certain drugs. It is important to stay abreast of the current literature on drug risks to effectively communicate these risks to patients, other health care providers, and the general public. OBJECTIVE: To summarize 4 new FDA drug safety communications by describing the evidence supporting the risks and the clinical implications for older adults. METHODS: The FDA Web site was reviewed for new drug safety communications from May 2011 to April 2012 that would be relevant to older adults. Approved labeling for each drug or class was obtained from the manufacturer, and PubMed was searched for primary literature that supported the drug safety concern. RESULTS: FDA drug safety communications for 4 drugs were chosen because of the potential clinical importance in older adults. A warning for citalopram was made because of potential problems with QT prolongation in patients taking less than 40 mg per day. The evidence suggests minor changes in QT interval. Given the flat dose-response curve in treating depression with citalopram, the new 20-mg/d maximum dose in older adults is sensible. Another warning was made for proton pump inhibitors (PPIs) and an increased risk of Clostridium difficile infection. A dose-response relationship was found for this drug risk. With C. difficile infections on the rise in older adults, along with other safety risks of PPI therapy, PPIs should only be used in older adults indicated for therapy for the shortest duration possible. In addition, a warning about dabigatran was made. There is strong evidence from a large clinical trial, as well as case reports, of increased bleeding risk in older adults taking dabigatran, especially in older adults with decreased renal function. This medication should be used with caution in older adults. Finally, several warnings were made about statins. Routine periodic monitoring of liver enzymes does not appear to be effective in detecting or preventing serious liver injury from statin use; thus, liver enzymes are no longer recommended to be routinely monitored. Statin-induced cognitive changes are rare, and insufficient evidence is currently available to establish causality. Statins appear to moderately increase the risk of developing diabetes (versus placebo), and regular screening for diabetes should be considered, especially for patients taking high-dose statins and patients with multiple risk factors for diabetes. CONCLUSION: FDA drug safety communications incorporate complex methodologies that investigate the risks (and relative benefits) of medication therapy. Clinicians caring for older adults need to be aware of the most current evidence behind these drug risks to effectively communicate with and care for their patients.
A year in review: new drugs for older adults in 2011.
Vande Griend JP, Marcum ZA, Linnebur SA
Am J Geriatr Pharmacother · 2012 Aug · PMID 22682643 · Full text
BACKGROUND: New drugs approved by the Food and Drug Administration (FDA) may offer tremendous clinical advances by providing health care providers with new treatment strategies. However, additional care must be taken for...
BACKGROUND: New drugs approved by the Food and Drug Administration (FDA) may offer tremendous clinical advances by providing health care providers with new treatment strategies. However, additional care must be taken for safe and effective use of these new agents by older adults. OBJECTIVE: Our objective was to identify FDA-approved medications in 2011 most likely to be prescribed to older adults, and to describe medication characteristics that may require special attention in this population. METHODS: The FDA Web site was reviewed for new drug approvals from January through December 2011. Approved labeling for each drug was obtained from the manufacturer's Web site and PubMed was searched for primary literature published between 1967 and 2012. RESULTS: Rivaroxaban, an oral factor Xa inhibitor, is approved for once-daily use in treatment of nonvalvular atrial fibrillation and deep vein thrombosis prophylaxis after replacement of a hip or knee. Drug interactions and renal function must be considered when prescribing this drug to older adults. Fidaxomicin is an oral anti-infective approved for the treatment of Clostridium difficile-associated diarrhea. It has minimal oral absorption or side effects, no relevant drug interactions, but a very high cost. It is a treatment option after failure of oral metronidazole and oral vancomycin. Roflumilast is a selective inhibitor of phosphodiesterase 4 and is approved to reduce the risk of chronic obstructive pulmonary disease (COPD) exacerbations in patients with severe COPD and a history of exacerbations. It is recommended as a second or alternative choice combined with a long-acting bronchodilator in patients at high risk for hospitalization. Indacaterol is an inhaled long-acting β-agonist approved for COPD maintenance. It is administered once daily, which may improve adherence in older adults compared with currently available twice-daily agents. CONCLUSIONS: Four new drugs approved in 2011 applicable to the geriatric population are presented. Clinicians must consider the available evidence, cost, drug-drug interactions, renal function, pharmacokinetic/pharmacodynamic differences, and patient preferences when considering prescribing these agents to older adults.
Medication adherence in older adults with cognitive impairment: a systematic evidence-based review.
Campbell NL, Boustani MA, Skopelja EN … +3 more , Gao S, Unverzagt FW, Murray MD
Am J Geriatr Pharmacother · 2012 Jun · PMID 22657941 · Publisher ↗
BACKGROUND: Cognitive impairment challenges the ability to adhere to the complex medication regimens needed to treat multiple medical problems in older adults. OBJECTIVE: Our aim was to conduct a systematic evidence-base...
BACKGROUND: Cognitive impairment challenges the ability to adhere to the complex medication regimens needed to treat multiple medical problems in older adults. OBJECTIVE: Our aim was to conduct a systematic evidence-based review to identify barriers to medication adherence in cognitively impaired older adults and interventions aimed at improving medication adherence. METHODS: A search of MEDLINE, EMBASE, PsycINFO, GoogleDocs, and CINAHL for articles published between 1966 and February 29, 2012 was performed. Studies included older adults with a diagnosis of cognitive impairment of any degree (mild cognitive impairment or mild, moderate, or severe dementia). To identify barriers to adherence, we reviewed observational studies. To identify relevant interventions, we reviewed clinical trials targeting medication adherence in cognitively impaired older adults. We excluded studies lacking a measure of medication adherence or lacking an assessment of cognitive function, case reports or series, reviews, and those focusing on psychiatric disorders or infectious diseases. Population demographics, baseline cognitive function, medication adherence methods, barriers to adherence, and prospective intervention methodologies were extracted. RESULTS: The initial search identified 594 articles. Ten studies met inclusion criteria for barriers to adherence and three met inclusion criteria for interventional studies. Unique barriers to adherence included understanding new directions, living alone, scheduling medication administration into the daily routine, using potentially inappropriate medications, and uncooperative patients. Two studies evaluated reminder systems and showed no benefit in a small group of participants. One study improved adherence through telephone and televideo reminders at each dosing interval. The results of the review are limited by reviewing only published articles, missing barriers or interventions due to lack of subgroup analysis, study selection and extraction completed by 1 reviewer, and articles with at least an abstract published in English. CONCLUSIONS: The few studies identified limit the assessment of barriers to medication adherence in the cognitively impaired population. Successful interventions suggest that frequent human communication as reminder systems are more likely to improve adherence than nonhuman reminders.
Influence of patient age and comorbid burden on clinician attitudes toward heart failure guidelines.
Steinman MA, Sudore RL, Peterson CA … +2 more , Harlow JB, Fried TR
Am J Geriatr Pharmacother · 2012 Jun · PMID 22579695 · Full text
BACKGROUND: Clinical practice guidelines have been criticized for insufficient attention to the unique needs of patients of advanced age and with multiple comorbid conditions. However, little empiric research is availabl...
BACKGROUND: Clinical practice guidelines have been criticized for insufficient attention to the unique needs of patients of advanced age and with multiple comorbid conditions. However, little empiric research is available to inform this topic. METHODS: We conducted telephone interviews with staff physicians and nurse practitioners in 4 VA health care systems. Respondents were asked to rate the usefulness of national heart failure guidelines for patients of different ages and levels of comorbid burden on a 5-point scale and to comment on the reasons for their ratings. RESULTS: Of 139 clinicians contacted, 65 (47%) completed the interview. Almost half (49%) were women, and 48 (74%) were general internists or family practitioners. On a 5-point scale assessing the usefulness of clinical practice guidelines for heart failure, the mean (SD) response ranged from 4.4 (0.7) for patients younger than 65 years with few comorbid conditions to 3.5 (1.2) for patients older than 80 years with multiple comorbid conditions (P<0.001). The difference in perceived usefulness varied more by patient age than by degree of comorbidity (P = 0.02). Four major concepts underlay the perceived usefulness of guidelines across different patient types: (1) harm of treatment and complexity of the patient's clinical condition and pharmacologic needs, (2) expected benefits of treatment, (3) patient preferences and abilities, and (4) confidence in the validity of guideline recommendations. CONCLUSION: Clinicians perceive heart failure guidelines to be substantially less useful in patients of older age and with greater comorbid burden. Concerns about the clinical and pharmacologic complexity of these patients and the expected benefits of drug therapy were commonly invoked as reasons for this skepticism.
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