The American Journal Of Geriatric Pharmacotherapy[JOURNAL]
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200 papers
Contraindicated medication use among patients in a memory disorders clinic.
Barton C, Sklenicka J, Sayegh P … +1 more , Yaffe K
Am J Geriatr Pharmacother · 2008 Aug · PMID 18775389 · Publisher ↗
BACKGROUND: Inappropriate or contraindicated use of medications in elderly patients is common and associated with poor outcomes. An important risk factor for adverse drug events is the increased sensitivity to drug effec...
BACKGROUND: Inappropriate or contraindicated use of medications in elderly patients is common and associated with poor outcomes. An important risk factor for adverse drug events is the increased sensitivity to drug effects on the central nervous system (CNS). There is a high rate of use of CNS-active drugs in patients with cognitive impairment, despite the fact that these medications may worsen cognition and be a possible "reversible" cause of memory loss. OBJECTIVES: The goals of this study were to establish the prevalence of these contraindicated medications in a population of elderly patients referred to a memory disorders clinic for evaluation and to determine if those individuals receiving contraindicated medications had specific characteristics. This included determining how many patients were concurrently being prescribed a cholinesterase inhibitor. METHODS: The review included new patients consecutively evaluated for cognitive complaints in a memory disorders clinic between June 2003 and August 2004. Each patient underwent a comprehensive evaluation by a multi-disciplinary team during a 3-hour clinic appointment. A thorough history of cognitive deficits and associated symptoms was obtained by the physician, who also performed a comprehensive neurologic examination. All patients underwent neuropsychologic testing with an extensive cognitive battery. In addition, patients' electronic medical records were reviewed to determine a list of prescribed and over-the-counter medications at the time of the initial referral. Contraindicated medications were identified using the updated Beers criteria of medications that should be avoided in older patients with cognitive impairment or that have high CNS adverse effects. RESULTS: A total of 100 patients (91 men, 9 women; mean [SD] age, 75.8 [9.7] years; 73% white) were included in the study. Eighty-six patients were determined at the time of evaluation to have some kind of cognitive impairment. They were mildly impaired, with a mean (SD) Mini-Mental State Examination score of 22.9 (5.1), based on a scale of 0 to 30. Twenty-two patients were taking > or =1 contraindicated medication that could potentially affect their cognition; the most frequently prescribed were benzodiazepines, oxybutynin, amitriptyline, fluoxetine, and diphenhydramine. Twenty-eight of the 100 patients were being treated with a cholinesterase inhibitor at the time of their evaluation; of these, 4 (14%) were also taking > or =1 medication with anticholinergic properties. CONCLUSIONS: Despite research evidence and recommendations to avoid these CNS-active medications because of their adverse effects, they continue to be prescribed in elderly patients with cognitive impairments. Further research is needed to determine strategies that will help reduce their administration in this population.
Risk of hospitalizations/emergency department visits and treatment costs associated with initial maintenance therapy using fluticasone propionate 500 microg/salmeterol 50 microg compared with ipratropium for chronic obstructive pulmonary disease in older adults.
Blanchette CM, Akazawa M, Dalal A … +1 more , Simoni-Wastila L
Am J Geriatr Pharmacother · 2008 Aug · PMID 18775388 · Publisher ↗
BACKGROUND: Cost-effective treatments for chronic obstructive pulmonary disease (COPD) are needed to reduce the burden on the Medicare system. OBJECTIVES: The objectives of this retrospective study were to compare the ef...
BACKGROUND: Cost-effective treatments for chronic obstructive pulmonary disease (COPD) are needed to reduce the burden on the Medicare system. OBJECTIVES: The objectives of this retrospective study were to compare the effects of fluticasone propionate 500 microg/salmeterol 50 microg (FSC 500/50) with those of ipratropium (IPR) in older adult patients with COPD on the following factors: (1) the risk of all-cause and COPD-related hospitalization and emergency department (ED) visits; and (2) all-cause and COPD-related treatment costs. METHODS: This retrospective, observational cohort study assessed commercially insured patients aged > or =65 years (Medicare eligible) with COPD-related medical costs (International Classification of Diseases, Ninth Revision, Clinical Modification codes 490.xx, 491.xx, 492.xx, or 496.xx), 18 months of continuous enrollment (12 months' pre-study and 6 months' poststudy), and > or =1 prescription claim (ie, the index event) for FSC 500/50 or IPR between January 2, 2001, and August 12, 2003. Exacerbation events (hospitalizations/ED visits) were assessed using Cox proportional hazards regression models controlling for baseline factors and preindex events. Treatment costs were estimated using multivariate generalized linear models to adjust for baseline characteristics and preindex utilization and costs. A propensity-matched comparison was conducted as a sensitivity analysis. RESULTS: A total of 1051 patients (540 women, 511 men) were identified: 952 in the IPR group (mean age, 74.26 years) and 99 in the FSC 500/50 group (mean age, 72.38 years). Treatment with FSC 500/50 was not associated with a reduction in the risk of all-cause hospitalization or ED visit compared with IPR (adjusted hazards ratio [HR], 0.913 [95% CI, 0.673-1.238]); however, FSC 500/50 was associated with a significantly lower risk (45%) of a COPD-related event (adjusted HR, 0.547 [95% CI, 0.301-0.995]). Although treatment with FSC 500/50 was associated with significantly lower annual mean all-cause medical costs compared with IPR ($18,642 vs $25,556, P < 0.05), the use of FSC 500/50 was also associated with significantly higher annual all-cause pharmacy costs ($2813 vs $2244, P < 0.05). Compared with the IPR cohort, the FSC 500/50 cohort had lower mean annual COPD-related medical costs (-$464 [P = NS]) and higher COPD-related pharmacy costs ($260 [P < 0.01]). However, increased pharmacy costs may be compensated for by decreased medical costs in both all-cause and COPD-related services. Results from the sensitivity analysis with the propensity score-matched sample of 194 patients were similar. CONCLUSIONS: Compared with the IPR cohort, the FSC 500/50 cohort was 45% less likely to have a COPD-related exacerbation event and had similar medical costs. FSC 500/50 was a more effective initial maintenance therapy than IPR for this Medicare population, and, despite the $260 increase in COPD-related pharmacy costs, there was no significant difference in COPD-related medical costs.
Use of computer decision support interventions to improve medication prescribing in older adults: a systematic review.
Yourman L, Concato J, Agostini JV
Am J Geriatr Pharmacother · 2008 Jun · PMID 18675770 · Publisher ↗
BACKGROUND: Older adults take multiple medications and are at high risk for adverse drug effects. OBJECTIVE: This systematic review was conducted to describe the impact of computer decision support (CDS) interventions de...
BACKGROUND: Older adults take multiple medications and are at high risk for adverse drug effects. OBJECTIVE: This systematic review was conducted to describe the impact of computer decision support (CDS) interventions designed to improve the quality of medication prescribing in older adults. METHODS: PubMed and EMBASE databases were searched from January 1980 through July 2007 (English-language only); studies were eligible if they described a CDS intervention intended to improve medication prescribing in adults aged > or =60 years. Studies were retained if they were observational or experimental in design and reported > or =1 process or clinical outcome measurement related to medication prescribing. In the main analysis, study characteristics and major outcome results were extracted. A combination of searches was performed using relevant medical subject headings: aged; drug therapy, computer-assisted; medication errors; medication errors/prevention and control; decision making, computer-assisted; decision support systems, clinical; and clinical pharmacy information systems. RESULTS: After review of study abstracts, 10 articles met the eligibility criteria. Of those 10 studies testing CDS interventions, 8 showed at least modest improvements (median number needed to treat, 33) in prescribing, as measured by minimizing drugs to avoid, optimizing drug dosage, or more generally improving prescribing choices in older adults (according to each study's intervention protocols). Findings for the impact of CDS interventions on clinical outcomes were mixed and were reported for only 2 studies. CONCLUSIONS: Various types of CDS interventions may be effective in improving medication prescribing in older adults, but few studies reported clinical outcomes related to changes in medication prescribing. Data from this study should help to guide refinement and testing of future CDS interventions that specifically target older adult populations that are taking multiple medications.
Cardiovascular risk factors and dementia.
Fillit H, Nash DT, Rundek T … +1 more , Zuckerman A
Am J Geriatr Pharmacother · 2008 Jun · PMID 18675769 · Publisher ↗
BACKGROUND: Dementias, such as Alzheimer's disease (AD) and vascular dementia, are disorders of aging populations and represent a significant economic burden. Evidence is accumulating to suggest that cardiovascular disea...
BACKGROUND: Dementias, such as Alzheimer's disease (AD) and vascular dementia, are disorders of aging populations and represent a significant economic burden. Evidence is accumulating to suggest that cardiovascular disease (CVD) risk factors may be instrumental in the development of dementia. OBJECTIVE: The goal of this review was to discuss the relationship between specific CVD risk factors and dementia and how current treatment strategies for dementia should focus on reducing CVD risks. METHODS: We conducted a review of the literature for the simultaneous presence of 2 major topics, cardiovascular risk factors and dementia (eg, AD). Special emphasis was placed on clinical outcome studies examining the effects of treatments of pharmacologically modifiable CVD risk factors on dementia and cognitive impairment. RESULTS: Lifestyle risk factors for CVD, such as obesity, lack of exercise, smoking, and certain psychosocial factors, have been associated with an increased risk of cognitive decline and dementia. Some evidence suggests that effectively managing these factors may prevent cognitive decline/dementia. Randomized, placebo-controlled trials of antihypertensive medications have found that such therapy may reduce the risk of cognitive decline, and limited data suggest a benefit for patients with AD. Some small open-label and randomized clinical trials of statins have observed positive effects on cognitive function; larger studies of statins in patients with AD are ongoing. Although more research is needed, current evidence indicates an association between CVD risk factors--such as hypertension, dyslipidemia, and diabetes mellitus--and cognitive decline/dementia. CONCLUSIONS: From a clinical perspective, these data further support the rationale for physicians to provide effective management of CVD risk factors and for patients to be compliant with such recommendations to possibly prevent cognitive decline/dementia.
Adverse effects of propafenone after long-term therapy with the addition of citalopram.
Garcia A
Am J Geriatr Pharmacother · 2008 Jun · PMID 18675768 · Publisher ↗
BACKGROUND: Propafenone, a class IC antiarrhythmic, and citalopram, a selective serotonin reuptake inhibitor (SSRI), are widely used in older patients. Although a potential interaction between propafenone and SSRIs has b...
BACKGROUND: Propafenone, a class IC antiarrhythmic, and citalopram, a selective serotonin reuptake inhibitor (SSRI), are widely used in older patients. Although a potential interaction between propafenone and SSRIs has been noted, a MEDLINE search revealed no published reports of an interaction between propafenone and citalopram. OBJECTIVE: The goal of this article was to describe a potential drug-drug interaction between propafenone and citalopram, which caused symptoms of propafenone adverse effects. CASE SUMMARY: An 80-year-old white female, followed up at the Memory Clinic for mild cognitive impairment, had been taking propafenone 900 mg/d for >10 years for paroxysmal atrial fibrillation without adverse effects. Three months after starting citalopram, she experienced episodes of chest tightness and dizziness. The episodes became more frequent in the following months, causing several falls and requiring visits to the emergency department, but no acute coronary event was diagnosed. She was started on amlodipine 2.5 mg orally once daily, a nitroglycerin patch (0.4 mg/h), and warfarin 5 mg orally once daily. After one fall, the patient became delirious. Amlodipine and the nitroglycerin patch were discontinued and propafenone decreased to 450 mg/d; citalopram was continued at 20 mg/d. The patient recovered well, both cognitively and physically, and did not have any further symptoms in 1 year of follow-up. Results of coronary investigations were negative. CONCLUSIONS: This is the first report of a possible interaction between propafenone and citalopram, which caused propafenone adverse effects (eg, dizziness, falls) and mimicked coronary artery disease.
Mirtazapine associated with profound hyponatremia: two case reports.
Cheah CY, Ladhams B, Fegan PG
Am J Geriatr Pharmacother · 2008 Jun · PMID 18675767 · Publisher ↗
BACKGROUND: Depression is a common problem in the elderly, and the recognition and appropriate management of this illness are important aspects of geriatric medicine. Selective serotonin reuptake inhibitors have been ass...
BACKGROUND: Depression is a common problem in the elderly, and the recognition and appropriate management of this illness are important aspects of geriatric medicine. Selective serotonin reuptake inhibitors have been associated with hyponatremia, but the association of mirtazapine with hyponatremia is less well documented. OBJECTIVE: The goal of this research was to highlight and characterize the association between mirtazapine and hyponatremia. We present here 2 case reports as well as the results of a literature review. CASE SUMMARIES: Two patients, a 61-year-old man and a 79-year-old woman, developed profound hyponatremia (sodium levels, 112 and 113 mEq/L, respectively) 7 and 10 days after commencement of mirtazapine for symptoms of depression. Investigations excluded other causes, and cessation of mirtazapine was associated with recovery of sodium levels to > or =132 mEq/L after 7 and 10 days, respectively. CONCLUSIONS: The likelihood of mirtazapine use causing hyponatremia in these 2 cases was "probable" according to criteria of the Naranjo Adverse Drug Reaction Probability Scale (score, 6). A review of published cases found that mirtazapine-associated hyponatremia occurred in patients aged >60 years, after a mean of 6.5 days and with doses as low as 7.5 mg daily. The mean sodium nadir was 117.2 mEq/L, but after stopping mirtazapine, the mean time to recovery was 11 days. Clinicians should be aware of the possibility of this reaction in elderly patients and should monitor sodium levels in high-risk patients if symptoms suggestive of hyponatremia develop.
A before and after study of medical students' and house staff members' knowledge of ACOVE quality of pharmacologic care standards on an acute care for elders unit.
Jellinek SP, Cohen V, Nelson M … +3 more , Likourezos A, Goldman W, Paris B
Am J Geriatr Pharmacother · 2008 Jun · PMID 18675766 · Publisher ↗
BACKGROUND: The Assessing Care of Vulnerable Elders (ACOVE) comprehensive set of quality assessment tools for ill older persons is a standard designed to measure overall care delivered to vulnerable elders (ie, those age...
BACKGROUND: The Assessing Care of Vulnerable Elders (ACOVE) comprehensive set of quality assessment tools for ill older persons is a standard designed to measure overall care delivered to vulnerable elders (ie, those aged > or =65 years) at the level of a health care system or plan. OBJECTIVE: The goal of this research was to quantify the pretest and posttest results of medical students and house staff participating in a pharmacotherapist-led educational intervention that focused on the ACOVE quality of pharmacologic care standards. METHODS: This was a before and after study assessing the knowledge ofACOVE standards following exposure to an educational intervention led by a pharmacotherapist. It was conducted at the 29-bed Acute Care for Elders (ACE) unit of Maimonides Medical Center, a 705-bed, independent teaching hospital located in Brooklyn, New York. Participants included all medical students and house staff completing a rotation on the ACE unit from August 2004 through May 2005 who completed both the pre-and posttests. A pharmacotherapist provided a 1-hour active learning session reviewing the evidence supporting the quality indicators and reviewed case-based questions with the medical students and house staff. Educational interventions also occurred daily through pharmacotherapeutic consultations and during work rounds. Medical students and house staff were administered the same 15-question, patient-specific, case-based, multiple-choice pre-and posttest to assess knowledge of the standards before and after receiving the intervention. RESULTS: A total of 54 medical students and house staff (median age, 28.58 years; 40 men, 14 women) completed the study. Significantly higher median scores were achieved on the multiple-choice test after the intervention than before (median scores, 14/15 [93.3%] vs 12/15 [80.0%], respectively; P = 0.001). CONCLUSION: A pharmacotherapist-led educational intervention improved the scores of medical students and house staff on a test evaluating knowledge of evidence-based recommendations for pharmacotherapy in the elderly.
Methodology of an ongoing, randomized controlled trial to prevent falls through enhanced pharmaceutical care.
Ferreri S, Roth MT, Casteel C … +2 more , Demby KB, Blalock SJ
Am J Geriatr Pharmacother · 2008 Jun · PMID 18675765 · Publisher ↗
BACKGROUND: Falls are the leading cause of both fatal and nonfatal injuries among adults aged > or =65 years in the United States. Past research suggests that individuals taking multiple medications are at increased risk...
BACKGROUND: Falls are the leading cause of both fatal and nonfatal injuries among adults aged > or =65 years in the United States. Past research suggests that individuals taking multiple medications are at increased risk of falls. Central nervous system-active drugs in particular have been associated with increased risk. OBJECTIVE: The goal of this research was to describe the design of a study evaluating the effectiveness of a community pharmacy-based falls prevention program. Also presented are the algorithms used to identify high-risk patients based on their prescription profile records and to deliver the experimental intervention. METHODS: The study is a randomized controlled trial. The target population was community-dwelling older adults (aged > or =65 years) at high risk for future falls because: (1) they had experienced > or =1 fall within the 12-month period preceding study enrollment; (2) they were currently using > or =4 chronic prescription medications; and (3) they were taking > or =1 of the high-risk medications targeted by the intervention. Participants were recruited using pharmacy prescription profile records. Individuals in the intervention group received a face-to-face medication consultation provided by a community pharmacy resident. Identification of drug therapy problems and therapeutic recommendations was guided by a series of algorithms developed for this study. All participants were followed up for 24 months. The primary study end points were: (1) time to first fall; and (2) proportion of participants who experienced > or =1 fall during the first year of follow-up. RESULTS: Participant enrollment began in September 2005 and was completed in August 2007. A total of 186 individuals were enrolled in the study (mean [SD] age, 74.8 [6.9] years; 132 women, 54 men), and 67 have completed the first year of follow-up. CONCLUSIONS: The study is using a rigorous randomized controlled research design, which will enhance the internal validity of its findings. Results of the study, which will be reported after the completion of follow-up data collection activities, will enable us to assess the effects of the intervention on both medication use and the incidence of falls. If the intervention is found to be effective, it will provide a resource for community pharmacists working with older adults at high risk of medication-related falls.
Effect of darbepoetin alfa administered once monthly on maintaining hemoglobin levels in older patients with chronic kidney disease.
Silver MR, Agarwal A, Krause M … +2 more , Lei L, Stehman-Breen C
Am J Geriatr Pharmacother · 2008 Jun · PMID 18675764 · Publisher ↗
BACKGROUND: The anemia of chronic kidney disease (CKD) is associated with increased hospitalizations, increased cardiovascular morbidity and mortality, and diminished quality of life in the elderly. Darbepoetin alfa is a...
BACKGROUND: The anemia of chronic kidney disease (CKD) is associated with increased hospitalizations, increased cardiovascular morbidity and mortality, and diminished quality of life in the elderly. Darbepoetin alfa is an erythropoiesis-stimulating agent that has been shown to be effective in treating anemia in patients with CKD (but not on dialysis) when administered using extended-dosing regimens. OBJECTIVE: The purpose of this post hoc analysis was to examine the efficacy and safety profile of once-monthly (QM) darbepoetin alfa in study patients stratified according to age (ie, <65, 65-74, and > or =75 years). METHODS: Patients with CKD but not on dialysis, receiving darbepoetin alfa every other week (Q2W), and with stable hemoglobin (Hb) levels between 11 and 13 g/dL, inclusive, were enrolled in this 33-week, multicenter, open-label, single-arm study. The study was carried out at 36 US centers and consisted of a 24-week QM darbepoetin alfa dose-titration period followed by an 8-week evaluation period. Hb levels were measured Q2W. Study results were stratified according to patient age (<65, 65-74, and > or =75 years). RESULTS: A total of 152 patients (79 women, 73 men) were enrolled; 55 patients (36%) were <65 years of age, 46 (30%) were 65 to 74 years of age, and 51 (34%) were > or =75 years of age. In patients who received > or =1 dose of darbepoetin alfa, Hb levels > or =11 g/dL were maintained in 76%, 80%, and 71% of patients aged <65, 65 to 74, and > or =75 years, respectively. For patients who completed the study, the proportions who maintained Hb levels > or =11 g/dL were 83%, 88%, and 85%, respectively, for the 3 age groups. The safety profile of QM darbepoetin alfa in this study was consistent with that expected in patients with CKD not receiving dialysis. CONCLUSIONS: Darbepoetin alfa administered QM maintained Hb levels > or =11 g/dL in patients with CKD (not on dialysis) aged <65, 65 to 74, and > or =75 years. This treatment regimen may help optimize anemia management for older community-dwelling and long-term care patients.
Intracerebral hemorrhage secondary to a warfarin-metronidazole interaction.
Howard-Thompson A, Hurdle AC, Arnold LB … +3 more , Finch CK, Sands C, Self TH
Am J Geriatr Pharmacother · 2008 Mar · PMID 18396247 · Publisher ↗
BACKGROUND: It has been >25 years since the interaction between warfarin and metronidazole was last reported in the literature. The current case report represents the first documentation of this interaction associated wi...
BACKGROUND: It has been >25 years since the interaction between warfarin and metronidazole was last reported in the literature. The current case report represents the first documentation of this interaction associated with intracerebral hemorrhage. CASE SUMMARY: We present a case of a 78-year-old white woman started on metronidazole (250 mg every 8 hours for 5 days) and levofloxacin (500 mg QD for 6 days) for an upper respiratory tract infection after visiting a walk-in clinic. The patient did not notify any of the health care professionals involved that she was on concomitant warfarin therapy, which had been stable over the last 3 months. Her warfarin dose was 7 mg daily, and her most recent international normalized ratio (INR) reading was 2.5. Nine days after her clinic visit, the patient was admitted to the hospital for a profuse nosebleed with an INR of 8.0 and was found to have an intraparenchymal hemorrhage of the left occipital lobe. The Naranjo adverse drug reaction probability scale indicated that the association with metronidazole was probable and the association with levofloxacin was possible (scores of 7 and 4, respectively). After a 1-week hospital stay, she was discharged. CONCLUSIONS: This adverse event is highly suggestive of a drug interaction caused primarily by metronidazole, which produces an increase in S-warfarin concentrations. Treatment provided by health care providers who were not familiar with the patient and the use of a different pharmacy (where the pharmacist was unaware of her current medications) likely contributed to the event.
Behavioral changes with paranoia in an elderly woman taking atorvastatin.
Peters JT, Garwood CL, Lepczyk M
Am J Geriatr Pharmacother · 2008 Mar · PMID 18396246 · Publisher ↗
BACKGROUND: There have been a number of published reports of central nervous system (CNS) adverse effects with statins. CASE SUMMARY: A 79-year-old woman developed paranoia, anxiety, and behavioral changes approximately...
BACKGROUND: There have been a number of published reports of central nervous system (CNS) adverse effects with statins. CASE SUMMARY: A 79-year-old woman developed paranoia, anxiety, and behavioral changes approximately 2.5 weeks after starting atorvastatin 10 mg/d. The patient had no other medication changes at this time. After 2 months of therapy, the patient discontinued atorvastatin, and her symptoms fully resolved after 4 days. CONCLUSIONS: This is the first case report, to our knowledge, describing paranoia as one of the symptoms associated with statin therapy. Our report suggests an adverse reaction due to the initiation of atorvastatin via the temporal relationship between the start of atorvastatin and symptom onset, as well as termination of therapy and subsequent symptom disappearance. Use of the Naranjo adverse drug reaction probability scale to assess causality revealed a "probable" association (score, 5) for this adverse event. This report emphasizes the possibility of paranoia as a CNS adverse effect due to statin therapy. Statins are frequently used in older populations and should therefore be considered when such CNS adverse effects occur during therapy.
Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices.
Wessell AM, Nietert PJ, Jenkins RG … +2 more , Nemeth LS, Ornstein SM
Am J Geriatr Pharmacother · 2008 Mar · PMID 18396245 · Publisher ↗
BACKGROUND: The use of potentially inappropriate medications (PIMs) in the elderly population is common. Interventions to decrease PIM use in primary care settings are needed. OBJECTIVE: This study was designed to assess...
BACKGROUND: The use of potentially inappropriate medications (PIMs) in the elderly population is common. Interventions to decrease PIM use in primary care settings are needed. OBJECTIVE: This study was designed to assess the time trends in use of always inappropriate and rarely appropriate medications in primary care patients aged >or=65 years during a quality improvement project. METHODS: A 4-year, prospective demonstration project was delivered to 99 primary care practices that use a common electronic medical record and are members of the Practice Partner Research Network. Each participating practice received quarterly performance reports on the use of always inappropriate and rarely appropriate medications in the elderly. Optional interventions included biannual on-site visits and annual network meetings for performance review, academic detailing, and quality improvement planning. General linear mixed regression models were used to analyze the change in prescribing rates over time. RESULTS: Across 42 months of project exposure, 124,802 active patients (61% women, 39% men) aged >or=65 years were included in the analyses. Among the 33 practices that participated in all 42 months of the intervention, the proportion of patients with a prescription for an always inappropriate medication decreased from 0.41% to 0.33%, and the proportion of patients with a prescription for a rarely appropriate medication decreased from 1.48% to 1.30%. Across all 99 practices, the adjusted absolute annual declines for the comprehensive categories of always inappropriate medications (00.018%, P = 0.03) and rarely appropriate medications (0.113%, P = 0.001) were statistically significant. Propoxyphene was the only individual medication that decreased significantly in use over time (baseline proportion, 0.72%; adjusted absolute annual decline, 0.072% [P = 0.001]). CONCLUSIONS: Always inappropriate and rarely appropriate medication use decreased over time in this practice-based research network study. Additional studies of robust interventions for improving medication use in the elderly are warranted.
Antidepressant use in nonmajor depression: secondary analysis of a program to encourage active, rewarding lives for seniors (PEARLS), a randomized controlled trial in older adults from 2000 to 2003.
Lakey SL, Gray SL, Ciechanowski P … +2 more , Schwartz S, Logerfo J
Am J Geriatr Pharmacother · 2008 Mar · PMID 18396244 · Publisher ↗
BACKGROUND: It is estimated that major depressive disorder affects 0.9% of community-dwelling older adults in the United States. However, as many as 18% of older US adults reportedly suffer from depressive symptoms that...
BACKGROUND: It is estimated that major depressive disorder affects 0.9% of community-dwelling older adults in the United States. However, as many as 18% of older US adults reportedly suffer from depressive symptoms that do not necessarily fit the criteria for major depressive disorder (eg, dysthmia, minor depression). OBJECTIVES: The goals of this study were to describe patterns of antidepressant medication use in older adults with dysthymia or minor depression and to examine factors associated with the use of antidepressants at baseline. METHODS: This was a secondary analysis using cross-sectional data collected during a randomized controlled trial conducted from 2000 through 2003. It involved community senior service agencies and in-home visits in Seattle, Washington. Adults aged >or=60 years who had minor depression or dysthymia and were receiving services through community senior service agencies or living in senior public housing were included. Study participants were classified as users or nonusers of antidepressants. Prescription medication use in the past 2 weeks was assessed at baseline and 6 and 12 months. Medication name, dose, and directions were recorded from the medication label. Logistic regression was used to examine variables associated with baseline antidepressant use. RESULTS: A total of 138 patients (mean age, 73.00 years) were included; the majority of study participants were female (779.00%). Overall, 42.33% were nonwhite (34.3% black, 4.4% Asian, 1.5% American Indian/Alaskan Native, 0.7% Hispanic, and 1.5% other). At baseline, 36.2% of study participants (n = 50) were using antidepressants. Selective serotonin reuptake inhibitors were the most common class of antidepressants, used by 62.00%, 70.22%, and 71.11% of antidepressant users at baseline, 6, and 12 months, respectively. However, nortriptyline was the most common antidepressant at baseline, taken by 20.00% of antidepressant users. Use of other prescription medications was associated with antidepressant use at baseline. CONCLUSIONS: We found antidepressant use to be low in these relatively poor, community-dwelling, ethnically diverse older adults with dysthymia and minor depression in 2000 through 2003, with 36.22% of participants using antidepressants at baseline. Antidepressant users were more likely to be taking other prescription medications than nonusers.
Risk factors for bleeding during anticoagulation of atrial fibrillation in older and younger patients in clinical practice.
Abdelhafiz AH, Wheeldon NM
Am J Geriatr Pharmacother · 2008 Mar · PMID 18396243 · Publisher ↗
BACKGROUND: The prevalence of atrial fibrillation increases with age, affecting approximately 5% of people aged >65 years and almost 10% of people aged >80 years. OBJECTIVE: The goal of this study was to identify risk fa...
BACKGROUND: The prevalence of atrial fibrillation increases with age, affecting approximately 5% of people aged >65 years and almost 10% of people aged >80 years. OBJECTIVE: The goal of this study was to identify risk factors for bleeding during warfarin treatment of nonvalvular atrial fibrillation (NNVAF) in older patients (those aged >or=75 years) compared with younger patients (those aged <75 years) in clinical practice. METHODS: All patients with NVAF newly started on warfarin at an anticoagulation clinic in a large university hospital were included in this prospective observational study. Patient details were recorded at their first visit; details of any bleeding events were recorded via telephone interview every 4 to 6 weeks for a minimum of 10 months. Patients were divided into 2 groups (ie, those >or=75 years old and those <75 years old). Logistic regression analysis was used to identify risk factors for bleeding. RESULTS: A total of 402 patients were included in the study. Group I comprised 203 patients <75 years old (mean [SD] age, 64.33 [8.33] years) and group II comprised 199 patients >or=75 years old (mean [SD] age, 80.44 [3.99] years). Follow-up ranged from 1 to 31 months (mean [SD], 19 [8.11] months). For major bleeding, number of medications was a significant risk factor in older patients (odds ratio [OR], 3.0; 95% CI, 1.2-7.8 [P = 0.02 ]) and range of the international normalized ratio (INR) was a significant risk factor in both groups. For every unit increase in the range of INR, the odds of major bleeding increased by 0.6 (OR, 1.6; 95% CI, 1.2-2.4 [P = 0.03 ]) in younger patients and by 0.4 (OR, 1.4; 95% CI, 1.07-1.99 [P = 0.04 ])in older patients. For minor bleeding, history of hypertension was the only significant risk factor in older patients (OR, 3.3; 95% CI, 1.3-8.1 [P = 0.01 ]), while history of ischemic heart disease was the only risk factor in younger patients (OR, 1.9; 95% CI, 1.1-5.4 [P = 0.04 ]). CONCLUSIONS: Bleeding pattern was similar in both age groups regarding severity, onset, anatomic site of bleeding, and INR values during the bleeding event. Risk factors for episodes of major bleeding, which are more of a clinical concern, are potentially modifiable. They include quality of anticoagulation control in both groups and number of medications in the older age group.
Deficiencies in our health care system when it comes to a crucial aspect of the process -- medications.
Prasanna CL
Am J Geriatr Pharmacother · 2007 Dec · PMID 18179997 · Publisher ↗
Abstract loading — click title to view on PubMed.
Pharmacologic prevention of aspiration pneumonia: a systematic review.
El Solh AA, Saliba R
Am J Geriatr Pharmacother · 2007 Dec · PMID 18179994 · Publisher ↗
BACKGROUND: Aspiration pneumonia is a common cause of morbidity and mortality. Several approaches, including bed positioning, dietary changes, and oral hygiene, have been proposed to prevent aspiration pneumonia, yet few...
BACKGROUND: Aspiration pneumonia is a common cause of morbidity and mortality. Several approaches, including bed positioning, dietary changes, and oral hygiene, have been proposed to prevent aspiration pneumonia, yet few data are available on the efficacy of pharmacologic interventions in reducing the rate of aspiration. OBJECTIVE: This study was a systematic literature review of the pharmacologic prevention of aspiration pneumonia. METHODS: We searched MEDLINE (1996-2006); EMBASE (1974-2006); Cumulative Index to Nursing & Allied Health Literature (CINAHL) (1982-2006); Health Services Technology, Administration, and Research (HealthSTAR) (1975-2006); and the Cochrane Library for relevant articles. References of all included articles were reviewed. Studies were included if they had a prospective, controlled design with a primary outcome of prevention of aspiration pneumonia. Surrogate outcomes that had a direct link to decreasing the incidence of aspiration pneumonia were considered. Selected articles were reviewed independently by 2 authors. RESULTS: Of 1108 studies reviewed, 20 were analyzed. Angiotensin-converting enzyme inhibitors may be beneficial in selected patients at high risk for aspiration. Capsaicin may be a low-risk approach to stimulate swallowing and cough reflexes. Amantadine, cabergoline, and theophylline may cause serious adverse events, and their routine use for prevention of aspiration pneumonia is not recommended. Cilostazol should not be used because of the increased risk for bleeding. CONCLUSIONS: Limited information is available on benefits and risks to guide an evidence-based approach to the pharmacologic prevention of aspiration pneumonia. Considering the high incidence of aspiration pneumonia in older adults, large randomized clinical trials on the effectiveness of pharmacologic interventions are warranted.
Polypharmacy in elderly patients.
Hajjar ER, Cafiero AC, Hanlon JT
Am J Geriatr Pharmacother · 2007 Dec · PMID 18179993 · Publisher ↗
BACKGROUND: Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly. OBJECTIVE: The go...
BACKGROUND: Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly. OBJECTIVE: The goal of this research was to provide a description of observational studies examining the epidemiology of polypharmacy and to review randomized controlled studies that have been published in the past 2 decades designed to reduce polypharmacy in older adults. METHODS: Materials for this review were gathered from a search of the MEDLINE database (1986-June 2007) and International Pharmaceutical Abstracts (1986-June 2007) to identify articles in people aged >65 years. We used a combination of the following search terms: polypharmacy, multiple medications, polymedicine, elderly, geriatric, and aged. 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 measured polypharmacy. RESULTS: The literature review found that polypharmacy continues to increase and is a known risk factor for important morbidity and mortality. There are few rigorously designed intervention studies that have been shown to reduce unnecessary polypharmacy in older adults. The literature review identified 5 articles, which are included here. All studies showed an improvement in polypharmacy. CONCLUSIONS: Many studies have found that various numbers of medications are associated with negative health outcomes, but more research is needed to further delineate the consequences associated with unnecessary drug use in elderly patients. Health care professionals should be aware of the risks and fully evaluate all medications at each patient visit to prevent polypharmacy from occurring.
Allergic interstitial nephritis possibly related to sunitinib use.
Khurana A
Am J Geriatr Pharmacother · 2007 Dec · PMID 18179992 · Publisher ↗
BACKGROUND: Sunitinib is an oral multitargeted inhibitor indicated for the treatment of renal cell carcinoma. OBJECTIVE: This report describes a case of allergic interstitial nephritis possibly related to this agent. CAS...
BACKGROUND: Sunitinib is an oral multitargeted inhibitor indicated for the treatment of renal cell carcinoma. OBJECTIVE: This report describes a case of allergic interstitial nephritis possibly related to this agent. CASE SUMMARY: A 69-year-old female patient with a history of metastatic renal cell carcinoma after left radical nephrectomy presented to our nephrology clinic after completing 2 courses of sunitinib therapy. The patient was noted to have progressive kidney dysfunction with proteinuria, together with peripheral eosinophilia and eosinophiluria, which developed during the first of 2 cycles of sunitinib therapy. Her concomitant medications included atenolol, triamterene/hydrochlorothiazide, amlodipine, and multivitamin tablets, all of which she had been receiving at stable doses over the previous 2 years. There were no other over-the-counter medications involved and other possible causes of interstitial nephritis were excluded. The proteinuria, eosinophilia, and eosinophiluria worsened with the second course and resolved after sunitinib discontinuation, which resulted in initial stabilization followed by slight improvement in kidney function. The Naranjo Adverse Drug Reaction Probability Scale score for this event was 7, indicating a probable association of the event with the drug. With clinical improvement after discontinuation of sunitinib and the presence of a solitary remaining kidney and thrombocytopenia, renal biopsy was not performed after discussion with the patient. When challenged with a related agent, sorafenib, the patient experienced worsening of serum creatinine and increasing eosinophilia, similar to that noted with sunitinib, suggesting that this event may be a class effect. CONCLUSIONS: Nephrologists and oncologists should be aware of allergic interstitial nephritis as an adverse effect related to this agent. Although there are no current recommendations for monitoring serum creatinine with sunitinib therapy, we recommend that serum creatinine and white cell count with differential be checked within 2 weeks of initiation of therapy with sunitinib to enable earlier diagnosis of this condition and avoid renal damage.
Distribution and correlates of serum 25-hydroxyvitamin D levels in a sample of patients with hip fracture.
Pieper CF, Colon-Emeric C, Caminis J … +7 more , Betchyk K, Zhang J, Janning C, Shostak J, LeBoff MS, Heaney RR, Lyles KW
Am J Geriatr Pharmacother · 2007 Dec · PMID 18179991 · Full text
BACKGROUND: Vitamin D deficiency is common in older populations, particularly during the winter months due to low levels of ultraviolet light exposure, and in nursing home residents. OBJECTIVE: The main objective of the...
BACKGROUND: Vitamin D deficiency is common in older populations, particularly during the winter months due to low levels of ultraviolet light exposure, and in nursing home residents. OBJECTIVE: The main objective of the current study was to assess the distribution of serum 25-hydroxyvitamin D and its correlates in a sample of men and women with recent hip fractures who were part of a large clinical trial. METHODS: This was a cross-sectional exploratory study of screened and ultimately randomized patients with hip fractures. They were part of a multinational (115 clinical centers in 20 countries), randomized, placebo-controlled, double-blind study testing the efficacy of a yearly IV bisphosphonate (zoledronic acid) in the prevention of new clinical fractures in patients with recent hip fracture repair. Levels of 25-hydroxyvitamin D, calcium, alkaline phosphatase, creatinine clearance, and albumin were measured at a screening visit using blood serum. Demographic variables were assessed by patient self-report. Bone mineral density (BMD) was assessed by dual-energy x-ray absorptiometry of the nonfractured hip. RESULTS: This report included 1174 screened patients (526 with vitamin D measured) and 655 (385 with vitamin D measured) patients randomized before the protocol amendment. In screened patients, levels of 25-hydroxyvitamin D were low (median, 14.7 ng/mL; interquartilc range, 7.6, 21.65). Overall, 51% were at or below the clinically meaningful threshold of 15 ng/mL. Among those patients randomized, the level of 25-hydroxyvitamin D was significantly positively related to male sex (rho, 0.13; P < 0.05), serum calcium (rho, 0.16; P < 0.01), and BMD at the femoral neck (rho, 0.22; P < 0.01) in bivariate analyses. Low serum 25-hydroxyvitamin D (<15 ng/mL) was related only to low serum calcium (odds ratio, 0.16; 95% CI, 0.05-0.52) in multivariable logistic models controlling for sex, age, race, body mass index, living at home, alkaline phosphatase, and creatinine clearance. CONCLUSIONS: We concluded that vitamin D insufficiency was a common problem in this population of elderly patients who had recently suffered a hip fracture. This insufficiency was related only to serum calcium in multivariable controlled models but cannot be reliably identified or excluded by measuring serum calcium alone. Physicians should be encouraged to check and monitor patients' serum levels of 25-hydroxyvitamin D.
Incontinence related to management of benign prostatic hypertrophy.
Han E, Black LK, Lavelle JP
Am J Geriatr Pharmacother · 2007 Dec · PMID 18179990 · Publisher ↗
BACKGROUND: The prevalence of incontinence ranges from 11% to 34% among community-dwelling men aged > or =65 years. OBJECTIVE: The objective of this analysis was to determine the nature of incontinence diagnosed in men w...
BACKGROUND: The prevalence of incontinence ranges from 11% to 34% among community-dwelling men aged > or =65 years. OBJECTIVE: The objective of this analysis was to determine the nature of incontinence diagnosed in men with benign prostatic hypertrophy (BPH), focusing on its incidence, prevalence, diagnostic workup, and management. METHODS: A cohort of patients with BPH was identified in the Integrated Healthcare Information Services National Managed Care Benchmark Database (1997-2003). Age and duration in the database after the first diagnosis of BPH were used as matching strata. Therapeutic subgroups consisted of watchful waiting, alpha-blockers, 5-alpha-reductase inhibitors (5ARIs), and BPH-related surgery. RESULTS: A total of 411,658 males with BPH were identified from 12,298,027 males (3.3%). Of the BPH cohort, 2.7% (n = 11,172) were identified as having incontinence; of these, 57.8% of patients were > or =65 years of age. Alter applying inclusion/exclusion criteria, the final matched case-control sample included 6346 men as case subjects and 229,154 men as control subjects. The overall incidence of incontinence in this BPH sample was 1835/100,000/year, and the prevalence was 2713/100,000 men. In 48.5% of the incontinent men, the type of incontinence was not specified. Diagnostic testing was performed in 2.9% of men with incontinence. Conditional logistic regression analyses found that BPH-related surgery and alpha-blocker use increased the adjusted odds ratio for the risk of incontinence 3.1-fold, and 1.1- to 1.7-fold, respectively. The odds ratio of the risk of incontinence was not significantly increased with long-term 5ARI use. CONCLUSIONS: Use of alpha-blockers, 5ARIs for the short term (<1 year), and BPH-related surgery were independently, significantly associated with BPH-related incontinence; 5ARI use for >1 year and watchful waiting were not. BPH-related incontinence may be related to progression of BPH or as a postsurgical complication. Patients with BPH should be asked specifically about incontinence, especially after BPH-related surgery, and undergo a full diagnostic workup for the diagnosis of urinary incontinence.
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