The American Journal Of Geriatric Pharmacotherapy[JOURNAL]
Sun
200 papers
Effects of oral bisphosphonate therapy on serum calcium in elderly veterans with poor kidney function.
Vouri SM, Alvarez CA, Blaszczyk AT
Am J Geriatr Pharmacother · 2012 Jun · PMID 22542895 · Publisher ↗
BACKGROUND: Limited data exist on the use of bisphosphonates in patients with poor kidney function due to a contraindication derived from inadequate experience among patients with kidney failure, accounting for as much a...
BACKGROUND: Limited data exist on the use of bisphosphonates in patients with poor kidney function due to a contraindication derived from inadequate experience among patients with kidney failure, accounting for as much as 25% of nonprescribing when otherwise appropriate. OBJECTIVES: To determine whether bisphosphonate use in patients with decreased renal function, as outlined in the package insert (estimated creatinine clearance [eCrCl] <35 mL/min), would result in higher rates of hypocalcemia, as suggested in previous studies. METHODS: This was a retrospective cohort study of elderly veterans 65 years of age and older at the Veterans Affairs North Texas Health Care System in Dallas, Texas. We identified 3089 patients who started oral bisphosphonate therapy between August 1, 2003 and July 12, 2010. Of the 252 patients meeting the inclusion criteria, 25 and 227 patients had an eCrCl <35 mL/min and eCrCl ≥35 mL/min, respectively. Analyses of changes in serum calcium from baseline to the 1-year study end point were performed within and between each renal function group. RESULTS: Among the veterans with an eCrCl <35 mL/min and eCrCl ≥35 mL/min, there were decreases in median serum calcium levels from baseline to study end point from 9.8 mg/dL (interquartile range [IQR], 9.4-10.2 mg/dL) to 9.3 mg/dL (IQR, 9.0-10.0 mg/dL; P = 0.028) and 9.6 mg/dL (IQR, 9.3-9.9 mg/dL) to 9.4 mg/dL (IQR, 9.1-9.8 mg/dL; P < 0.001), respectively. However, there was no difference in Δcalcium: -0.2 mg/dL (IQR, 0-0.6 mg/dL) and 0.2 mg/dL (IQR, -0.2 to 0.5 mg/dL; P = 0.547), respectively. CONCLUSIONS: This exploratory assessment may suggest that, in elderly veterans, the initiation of oral bisphosphonate therapy contributed to a statistically significant decrease in serum calcium levels regardless of baseline renal function; however, the clinical impact of this change does not appear to be significant. Future studies should assess serum calcium in a larger population of patients to confirm the safety of oral bisphosphonates in poor kidney function.
The greater sensitivity of elderly APOE ε4 carriers to anticholinergic medications is independent of cerebrovascular disease risk.
Nebes RD, Pollock BG, Perera S … +2 more , Halligan EM, Saxton JA
Am J Geriatr Pharmacother · 2012 Jun · PMID 22534472 · Full text
BACKGROUND: Recent studies found use of anticholinergic medications to be associated with greater performance decrements in older persons who carry an ε4 allele of the apolipoprotein E (APOE) gene than in those carrying...
BACKGROUND: Recent studies found use of anticholinergic medications to be associated with greater performance decrements in older persons who carry an ε4 allele of the apolipoprotein E (APOE) gene than in those carrying only ε2 or ε3 alleles. OBJECTIVES: The present study examined whether the apparently greater behavioral toxicity of anticholinergic drugs in ε4 carriers may result from an increased risk of cerebrovascular disease, which is more common in ε4 carriers. METHODS: Cross-sectional data were available from 240 elderly community volunteers who had participated in 2 different studies of the cognitive and motor effects of normal aging. As part of these studies, information was gathered on subjects' use of anticholinergic medications (based on an inventory of medications taken within 24 hours of testing), risk of cerebrovascular disease (Framingham Stroke Risk Profile), and APOE genotype. Performance data were also available from measures of general cognitive status (Mini-Mental State Examination), executive function (Trail Making Test), mood (Geriatric Depression Scale), sleep (Pittsburgh Sleep Quality Index), and walking speed. Logistic and linear regression models were used to examine how outcomes differed between genotypes and drug use, independent of the risk of cerebrovascular disease. RESULTS: In persons with a non-ε4 genotype, anticholinergic medication use did not significantly affect any of the behavioral measures. By contrast, among ε4 carriers, those taking anticholinergic drugs performed significantly worse than did those not taking such drugs on tests of general cognitive status, executive function, mood, and sleep. Adjusting for participants' stroke risk had a minimal effect on these results. CONCLUSIONS: Anticholinergic medication use was associated with poorer performance on measures of cognition, sleep, and mood only in older persons who carried 1 or more ε4 alleles of the APOE gene; this effect did not appear to be the result of an increased risk of cerebrovascular disease.
Association of chronic obstructive pulmonary disease maintenance medication adherence with all-cause hospitalization and spending in a Medicare population.
Simoni-Wastila L, Wei YJ, Qian J … +5 more , Zuckerman IH, Stuart B, Shaffer T, Dalal AA, Bryant-Comstock L
Am J Geriatr Pharmacother · 2012 Jun · PMID 22521808 · Publisher ↗
BACKGROUND: Although maintenance medications are a cornerstone of chronic obstructive pulmonary disease (COPD) management, adherence remains suboptimal. Poor medication adherence is implicated in poor outcomes with other...
BACKGROUND: Although maintenance medications are a cornerstone of chronic obstructive pulmonary disease (COPD) management, adherence remains suboptimal. Poor medication adherence is implicated in poor outcomes with other chronic conditions; however, little is understood regarding links between adherence and outcomes in COPD patients. OBJECTIVE: This study investigates the association of COPD maintenance medication adherence with hospitalization and health care spending. METHODS: Using the 2006 to 2007 Chronic Condition Warehouse administrative data, this retrospective cross-sectional study included 33,816 Medicare beneficiaries diagnosed with COPD who received at least 2 prescriptions for ≥1 COPD maintenance medications. After a 6-month baseline period (January 1, 2006 to June 30, 2006), beneficiaries were followed through to December 31, 2007 or death. Two medication adherence measures were assessed: medication continuity and proportion of days covered (PDC). PDC values ranged from 0 to 1 and were calculated as the number of days with any COPD maintenance medication divided by duration of therapy with these agents. The association of adherence with all-cause hospital events and Medicare spending were estimated using negative binomial and γ generalized linear models, respectively, adjusting for sociodemographics, Social Security disability insurance status, low-income subsidy status, comorbidities, and proxy measures of disease severity. RESULTS: Improved adherence using both measures was significantly associated with reduced rate of all-cause hospitalization and lower Medicare spending. Patients who continued with their medications had lower hospitalization rates (relative rate [RR] = 0.88) and lower Medicare spending (-$3764), compared with patients who discontinued medications. Similarly, patients with PDC ≥0.80 exhibited lower hospitalization rates (RR = 0.90) and decreased spending (-$2185), compared with patients with PDC <0.80. CONCLUSIONS: COPD patients with higher adherence to prescribed regimens experienced fewer hospitalizations and lower Medicare costs than those who exhibited lower adherence behaviors. Findings suggested the clinical and economic importance of medication adherence in the management of COPD patients in the Medicare population.
Commentary on the new American Geriatric Society Beers criteria for potentially inappropriate medication use in older adults.
Marcum ZA, Hanlon JT
Am J Geriatr Pharmacother · 2012 Apr · PMID 22483163 · Full text
Abstract loading — click title to view on PubMed.
Case report: Post-traumatic memories triggered by donepezil in a dose-dependent pattern.
Wolff ML
Am J Geriatr Pharmacother · 2012 Jun · PMID 22445625 · Publisher ↗
BACKGROUND: This case report describes a new adverse drug event due to use of donepezil in a patient with probable Alzheimer's Disease. CASE SUMMARY: While receiving a 10-mg dose of donepezil nightly, an 87-year old vete...
BACKGROUND: This case report describes a new adverse drug event due to use of donepezil in a patient with probable Alzheimer's Disease. CASE SUMMARY: While receiving a 10-mg dose of donepezil nightly, an 87-year old veteran of World War II experienced irrepressible memories of a kamikaze strike. This symptom did not occur at a 5-mg dose of donepezil and resolved with downward titration of this agent. CONCLUSIONS: This sequence of dosage and symptoms suggests acetylcholinesterase inhibition was the trigger for release of these memories, which are otherwise mostly chronically repressed in this individual.
Differences in lithium use patterns in the Netherlands: comparing middle-aged and older patients in a database study.
van Melick EJ, Wilting I, Souverein PC … +1 more , Egberts TC
Am J Geriatr Pharmacother · 2012 Jun · PMID 22417731 · Publisher ↗
BACKGROUND: Age-dependent changes in lithium pharmacokinetic and pharmacodynamic properties can influence lithium use in an aging population, especially as newer treatment options are available. OBJECTIVE: We compared li...
BACKGROUND: Age-dependent changes in lithium pharmacokinetic and pharmacodynamic properties can influence lithium use in an aging population, especially as newer treatment options are available. OBJECTIVE: We compared lithium use patterns between middle-aged and elderly outpatients in the Netherlands. METHODS: Data for this study were obtained from the Dutch PHARMO Record Linkage System. Incident lithium users 40 years or older were identified in the period 1996-2008. The following lithium use patterns were defined: continuation, add on, switch, and discontinuation. Differences were assessed for the following age groups: 40 to 49 years, 50 to 59 years, 60 to 69 years, and 70 years or older. The youngest group was the reference group. Patient baseline characteristics and potential determinants of changes in lithium use patterns were assessed. RESULTS: We identified 2081 incident lithium users. Use of antidepressants was not different at baseline between age groups, but elderly patients starting lithium treatment used baseline antipsychotics less frequently (P < 0.05). Older patients were less likely to receive psychotropic drugs as add on to ongoing lithium therapy (P < 0.05). Frequency of discontinuation and switch events did not differ between the age groups. In the whole study group, age was associated with any change in lithium use patterns. CONCLUSIONS: Older patients are less likely to receive psychotropic drugs as add on to ongoing lithium therapy. Despite pharmacokinetic and pharmacodynamic changes in the elderly, lithium is not more often discontinued and not more often switched in older patients.
Role of the pharmacist on a general medicine acute care for the elderly unit.
Reilly T, Barile D, Reuben S
Am J Geriatr Pharmacother · 2012 Apr · PMID 22387106 · Publisher ↗
BACKGROUND: The prevalence of prescription medication use increases with age, and older adults are at increased risk of harm from medication use. OBJECTIVE: To describe the role of a pharmacist on a General Medicine Acut...
BACKGROUND: The prevalence of prescription medication use increases with age, and older adults are at increased risk of harm from medication use. OBJECTIVE: To describe the role of a pharmacist on a General Medicine Acute Care of the Elderly (GM-ACE) Unit. METHODS: A job description was prepared, and a clinical pharmacist specializing in internal medicine was re-assigned to participate in multidisciplinary rounds on the ACE unit twice weekly and to work with a unit-based pharmacist assigned to multiple units. The clinical pharmacist also provided formal education on geriatric pharmacotherapy for other health care providers. Interventions were defined as changes in the medical record and provision of drug information. Interventions were tracked with an existing form and sorted by category. Data on interventions were presented to the pharmacy and therapeutics committee routinely. RESULTS: After 3 months, the clinical pharmacist accomplished 76 interventions in the areas of agent selection, dose optimization, addition of therapy, deletion of therapy, medication reconciliation, intravenous to oral conversion, technology improvements, and drug information/patient education. CONCLUSION: Expanding the role of the pharmacist in a GM-ACE unit has improved the medication use process in a high-risk population through improvements in medication overuse, medication underuse, dosing, medication reconciliation, patient education, and health care provider education.
Polypharmacy with common diseases in hospitalized elderly patients.
Mizokami F, Koide Y, Noro T … +1 more , Furuta K
Am J Geriatr Pharmacother · 2012 Apr · PMID 22387105 · Publisher ↗
BACKGROUND: Elderly persons are exposed to polypharmacy because of multiple chronic conditions. Many risk factors for polypharmacy have been identified including age, race/ethnicity, sex, educational achievement level, h...
BACKGROUND: Elderly persons are exposed to polypharmacy because of multiple chronic conditions. Many risk factors for polypharmacy have been identified including age, race/ethnicity, sex, educational achievement level, health status, and number of chronic diseases. However, drugs prescribed for individual diseases have not been analyzed. OBJECTIVE: The objective of this study was to analyze each common disease in the elderly with respect to prescribed drugs and polypharmacy. METHODS: A 1-year (January through December 2009) cross-sectional study was performed in which all drugs given to hospitalized elderly patients (age, >65 years) were investigated. Common diseases of the elderly were separated into disease groups including hypertension, hyperlipidemia, gastric ulcer, previous stroke, reflux esophagitis, diabetes mellitus, malignancy, osteoporosis, angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, dementia, and depression. RESULTS: Among 1768 elderly patients, the mean (range) age of study patients was 78 (65 to 100) years. The mean (SD) number of diseases was 7.7 (3.4), and the number of drugs overall was 4.9 (3.6). The number of drugs and prevalence of polypharmacy were hypertension, 5.2 (3.9 [51%]); hyperlipidemia, 5.6 (3.8 [58%]); gastric ulcer, 5.4 (3.8 [53%]); previous stroke, 5.8 (3.2 [61%]); reflux esophagitis, 5.6 (3.8 [40%]), diabetes mellitus, 5.6 (3.1 [54%]); malignancy, 4.1 (3.1 [37%]); osteoporosis, 5.4 (3.4 [45%]); angina pectoris, 5.7 (3.6 [42%]); congestive heart failure, 6.1 (4.0 [60%]); chronic obstructive pulmonary disease, 5.0 (3.5 [53%]); dementia, 5.1 (3.2 [52%]); and depression, 7.0 (4.2 [73%]). CONCLUSIONS: When assessing the risk of polypharmacy, physicians should carefully consider the type of any chronic disease. Elderly patients with multiple diseases may be subjected to further polypharmacy.
Clinical challenges in a patient with dabigatran-induced fatal hemorrhage.
Cano EL, Miyares MA
Am J Geriatr Pharmacother · 2012 Apr · PMID 22386824 · Publisher ↗
OBJECTIVE: To report clinical challenges in managing dabigatran-induced bleeding. METHODS: A 78-year-old woman came to the hospital with severe coagulopathy, respiratory failure, hypotension, and bleeding secondary to da...
OBJECTIVE: To report clinical challenges in managing dabigatran-induced bleeding. METHODS: A 78-year-old woman came to the hospital with severe coagulopathy, respiratory failure, hypotension, and bleeding secondary to dabigatran therapy. At admission, creatinine clearance was 15 mL/min; prothrombin time, 147.5 seconds; activated partial thromboplastin time, >200 seconds; and international normalized ratio, 12.42. Medications taken at home included dabigatran, 150 mg BID. During the hospitalization, multiple blood product transfusions were given, vitamin K and prothrombin complex concentrate were administered, and dialysis was initiated in an attempt to achieve hemostasis. Despite multiple interventions, coagulopathy persisted (prothrombin time, 70.8 seconds; activated partial thromboplastin time, >200 seconds; and international normalized ratio, 6.05), with continued bleeding. On hospital day 5, the patient died. CONCLUSIONS: According to the Naranjo probability scale, bleeding associated with dabigatran revealed a probable relationship. This fatal case illustrates our concern about the usefulness of currently recommended anticoagulation laboratory tests and of the efficacy of blood transfusion, dialysis, and prothrombin complex concentrate in managing life-threatening bleeding secondary to dabigatran. In addition, clinicians should be cognizant of the renal recommendations for the newer oral anticoagulant agents to prevent potentially catastrophic results.
Reconsideration of key articles regarding medication-related problems in older adults from 2011.
Thorpe CT, Lassila HC, O'Neil CK … +3 more , Thorpe JM, Hanlon JT, Maher RL
Am J Geriatr Pharmacother · 2012 Feb · PMID 22330099 · Full text
Abstract loading — click title to view on PubMed.
Risk of falls and fractures in older adults using atypical antipsychotic agents: a propensity score-adjusted, retrospective cohort study.
Chatterjee S, Chen H, Johnson ML … +1 more , Aparasu RR
Am J Geriatr Pharmacother · 2012 Apr · PMID 22306198 · Publisher ↗
BACKGROUND: Atypical antipsychotic agents are extensively prescribed in the elderly to treat various behavioral and psychiatric disorders. Past literature has documented an increased risk of falls and factures with the u...
BACKGROUND: Atypical antipsychotic agents are extensively prescribed in the elderly to treat various behavioral and psychiatric disorders. Past literature has documented an increased risk of falls and factures with the use of risperidone and olanzapine compared with nonuse. However, none of the studies assessed the comparative safety profiles of atypical agents with respect to falls and fractures. OBJECTIVE: The goal of this study was to evaluate the risk of falls and fractures associated with the use of risperidone, olanzapine, and quetiapine in community-dwelling adults aged ≥50 years. METHODS: The study involved a propensity score-adjusted approach in new users of risperidone, olanzapine, or quetiapine anytime between July 1, 2000, and June 30, 2008, using data from the IMS LifeLink Health Plan Claims database. Patients were followed up until a hospitalization/emergency department visit for fall/fracture or the end of the study period, whichever occurred earlier. The Cox proportional hazards regression model was used to evaluate the comparative risk of falls/fractures. The covariates in the final model included propensity scores and their interaction terms. RESULTS: There were 12,145 new users of atypical agents in the study population (5083 risperidone, 4377 olanzapine, and 2685 quetiapine). A total of 417 cases of falls/fractures with at least 1 hospitalization/ emergency department visit after the use of the antipsychotic agents were identified. The number of falls for risperidone, olanzapine, and quetiapine were 179 (3.56%), 123 (2.84%), and 115 (4.34%), respectively. After adjusting for propensity scores, the Cox proportional hazards model showed that there was no statistically significant difference with use of risperidone (hazard ratio = 1.10 [95% CI, 0.86-1.39]) or quetiapine (hazard ratio = 1.12 [95% CI, 0.86-1.46]) compared with olanzapine (reference group) in the risk of falls or fractures. CONCLUSIONS: The study found no significant difference across the individual atypical agents in the risk of falls/fractures in community-dwelling older adults. Future studies are required to evaluate the overall safety profiles of the antipsychotic agents in this population.
Applicability of an adapted medication appropriateness index for detection of drug-related problems in geriatric inpatients.
Somers A, Mallet L, van der Cammen T … +2 more , Robays H, Petrovic M
Am J Geriatr Pharmacother · 2012 Apr · PMID 22304791 · Publisher ↗
BACKGROUND: High drug consumption by older patients and the presence of many drug-related problems require careful assessment of drug therapy, for which a structured approach is recommended. OBJECTIVE: The purpose of our...
BACKGROUND: High drug consumption by older patients and the presence of many drug-related problems require careful assessment of drug therapy, for which a structured approach is recommended. OBJECTIVE: The purpose of our study was to evaluate the applicability of an adapted version of the Medication Appropriateness Index (MAI) in 50 geriatric inpatients at the time of admission. METHODS: We reviewed, for 432 prescribed drugs, indication, right choice, dosage, directions, drug-disease interactions, drug-drug interactions, and duration of therapy. In addition, adverse drug reactions were evaluated, resulting in 8 questions per drug. MAI scores were attributed independently by a geriatrician and by a clinical pharmacist, and differences between them were assessed. Furthermore, the relationship between MAI score and drug-related hospital admission was explored. RESULTS: Mean summed MAI scores of 13.7 according to the geriatrician and 13.6 according to the pharmacist were obtained. The highest scores were found for drugs for the central nervous and the urinary tract system; the highest scores per question were detected for right choice, adverse drug reactions, and drug-drug interactions. A good agreement between the scores of the geriatrician and the pharmacist was found: intraclass correlation coefficient was 0.91 and overall κ value was 0.71. A significantly higher MAI score was found for drug-related hospital admissions (P = 0.04 for the geriatrician and P = 0.03 for the pharmacist). CONCLUSIONS: This adapted MAI score seems useful for detection of drug-related problems in geriatric inpatients and reliable with a low inter-rater variability and positive correlation between high score and drug-related hospital admission. We consider further application of the adapted MAI for teaching and training of clinical pharmacists, and as a systematic approach for detection of drug-related problems by the clinical pharmacists in our hospital.
Age-related changes in antidepressant pharmacokinetics and potential drug-drug interactions: a comparison of evidence-based literature and package insert information.
Boyce RD, Handler SM, Karp JF … +1 more , Hanlon JT
Am J Geriatr Pharmacother · 2012 Apr · PMID 22285509 · Full text
BACKGROUND: Antidepressants are among the most commonly prescribed psychotropic agents for older patients. Little is known about the best source of pharmacotherapy information to consult about key factors necessary to sa...
BACKGROUND: Antidepressants are among the most commonly prescribed psychotropic agents for older patients. Little is known about the best source of pharmacotherapy information to consult about key factors necessary to safely prescribe these medications to older patients. OBJECTIVE: The objective of this study was to synthesize and contrast information in the package insert (PI) with information found in the scientific literature about age-related changes of antidepressants in systemic clearance and potential pharmacokinetic drug-drug interactions (DDIs). METHODS: A comprehensive search of two databases (MEDLINE and EMBASE from January 1, 1975 to September 30, 2011) with the use of a combination of search terms (antidepressants, pharmacokinetics, and drug interactions) was conducted to identify relevant English language articles. This information was independently reviewed by two researchers and synthesized into tables. These same two researchers examined the most up-to-date PIs for the 26 agents available at the time of the study to abstract quantitative information about age-related decline in systemic clearance and potential DDIs. The agreement between the two information sources was tested with κ statistics. RESULTS: The literature reported age-related clearance changes for 13 antidepressants, whereas the PIs only had evidence about 4 antidepressants (κ < 0.4). Similarly, the literature identified 45 medications that could potentially interact with a specific antidepressant, whereas the PIs only provided evidence about 12 potential medication-antidepressant DDIs (κ < 0.4). CONCLUSION: The evidence-based literature compared with PIs is the most complete pharmacotherapy information source about both age-related clearance changes and pharmacokinetic DDIs with antidepressants. Future rigorously designed observational studies are needed to examine the combined risk of antidepressants with age-related decline in clearance and potential DDIs on important health outcomes such as falls and fractures in older patients.
Design of a medication therapy management program for Medicare beneficiaries: qualitative findings from patients and physicians.
Lauffenburger JC, Vu MB, Burkhart JI … +2 more , Weinberger M, Roth MT
Am J Geriatr Pharmacother · 2012 Apr · PMID 22284582 · Full text
BACKGROUND: The quality of pharmacologic care provided to older adults is less than optimal. Medication therapy management (MTM) programs delivered to older adults in the ambulatory care setting may improve the quality o...
BACKGROUND: The quality of pharmacologic care provided to older adults is less than optimal. Medication therapy management (MTM) programs delivered to older adults in the ambulatory care setting may improve the quality of medication use for these individuals. OBJECTIVES: We conducted focus groups with older adults and primary care physicians to explore (1) older adults' experiences working with a clinical pharmacist in managing medications, (2) physician perspectives on the role of clinical pharmacists in facilitating medication management, and (3) key attributes of an effective MTM program and potential barriers from patient and provider perspectives. METHODS: Five focus groups (4 with older adults, 1 with physicians) were conducted by a trained moderator using a semistructured interview guide. Each participant completed a demographic questionnaire. Sessions were recorded, transcribed verbatim, and analyzed using qualitative analysis software for theme identification. RESULTS: Twenty-eight older adults and 8 physicians participated. Older adults valued the professional, trusting nature of their interactions with the pharmacist. They found the clinical pharmacist to be a useful resource, thorough, personable, and a valuable team member. Physicians believe that the clinical pharmacist fills a unique role as a specialized practitioner, contributing meaningfully to patient care. Physicians emphasized the importance of effective communication, pharmacist access to the medical record, and a mutually trusting relationship as key attributes of a program. Potential barriers to an effective program include poor communication and lack of familiarity with the patient's history. The lack of a sustainable reimbursement model was cited as a barrier to widespread implementation of MTM. CONCLUSIONS: This study provides information to assist pharmacists in designing MTM programs in the ambulatory setting. Key attributes of an effective program include being comprehensive and addressing all medication-related needs over time. The clinical pharmacist's ability to build trusting relationships with patients and providers is essential.
Complexity of medication use in newly diagnosed chronic obstructive pulmonary disease patients.
Solem CT, Lee TA, Joo MJ … +3 more , Lambert BL, Walton SM, Pickard AS
Am J Geriatr Pharmacother · 2012 Apr · PMID 22280978 · Publisher ↗
BACKGROUND: To better understand how medications have been used and the complexity of regimens used to treat patients, we characterized patterns of medication use and the degree to which patients used different classes o...
BACKGROUND: To better understand how medications have been used and the complexity of regimens used to treat patients, we characterized patterns of medication use and the degree to which patients used different classes of medications in combination and over time in a cohort of newly diagnosed chronic obstructive pulmonary disease (COPD) patients. OBJECTIVE: The objectives of this study were to characterize patterns of medication use, including the degree to which patients used different classes of medications in combination and over time within a cohort of newly diagnosed COPD patients and to identify the proportion of patients who had gaps in filling their prescriptions. METHODS: We identified a cohort of patients from the Veterans Affairs health care system with newly diagnosed COPD between 1999 and 2003. Using prescription fill information, we quantified the prevalence and incidence of exposure to short-acting β-agonists (SABAs), long-acting β-agonists (LABAs), short-acting anticholinergics (eg, ipratropium [IPRA]), and inhaled corticosteroids (ICSs) over 1 year. We additionally characterized the sequencing of medication addition and discontinuation and gaps between prescription fills. The prevalence of multiple respiratory medication use was summarized at 90, 180, and 365 days of follow-up. RESULTS: Of 133,737 patients with newly diagnosed COPD, the majority (80.0%) used a SABA, followed by 40.0% using IPRA, 33.2% using an ICS and 16.0% using a LABA during the 1-year follow-up. Medication changes were frequent, with 57.7% of patients having a medication addition and 48.6% discontinuing medication. The sequence of medication changes varied greatly across patients. Multiple respiratory medication use was common, with 29% of patients dispensed 3 to 4 medication classes in 1 year. CONCLUSIONS: Many COPD patients who are started on medication management undergo changes in prescribed pharmacotherapy and are taking multiple medications. Despite clinical practice guidelines, there is an ad hoc nature of COPD medication management, and such heterogeneity challenges the ability to estimate relationships between drug exposure and outcomes using real-world data.
Challenge of changing nursing home prescribing culture.
Tjia J, Gurwitz JH, Briesacher BA
Am J Geriatr Pharmacother · 2012 Feb · PMID 22264855 · Full text
This article described a framework for improving prescribing in nursing homes (NH) by focusing on the whole facility as a system that has created a "prescribing culture." We offered this paradigm as an alternative to foc...
This article described a framework for improving prescribing in nursing homes (NH) by focusing on the whole facility as a system that has created a "prescribing culture." We offered this paradigm as an alternative to focused interventions that target prescribers only. We used the example of atypical antipsychotics to illustrate the approach. We also highlighted elements of the NH culture change movement that are germane to medication prescribing, and illustrated which elements of NH culture were shown to be associated with suboptimal quality of care. We concluded by describing current models, including our study funded by the Agency for Healthcare Research and Quality, to identify the best methods of disseminating evidence-based medication use guides in NHs.
The effect of dementia on medication use and adherence among Medicare beneficiaries with chronic heart failure.
Rattinger GB, Dutcher SK, Chhabra PT … +5 more , Franey CS, Simoni-Wastila L, Gottlieb SS, Stuart B, Zuckerman IH
Am J Geriatr Pharmacother · 2012 Feb · PMID 22264854 · Full text
BACKGROUND: Alzheimer's disease and related disorders (ADRD) are prevalent in older adults, increase the costs of chronic heart failure (CHF) management, and may be associated with undertreatment of cardiovascular diseas...
BACKGROUND: Alzheimer's disease and related disorders (ADRD) are prevalent in older adults, increase the costs of chronic heart failure (CHF) management, and may be associated with undertreatment of cardiovascular disease. OBJECTIVE: The purpose of our study was to determine the relationship between comorbid ADRD and CHF medication use and adherence among Medicare beneficiaries with CHF. METHODS: This 2-year (1/1/2006-12/31/2007) cross-sectional study used data from the Chronic Condition Data Warehouse of the Centers for Medicare and Medicaid Services. Medicare beneficiaries with evidence of CHF who had systolic dysfunction and Medicare Parts A, B, and D coverage during the entire study period were included. ADRD was identified based on diagnostic codes using the Chronic Condition Data Warehouse algorithm. CHF evidence-based medications (EBMs) were selected based on published guidelines: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, selected β-blockers, aldosterone antagonists, and selected vasodilators. Measures of EBMs included a binary indicator of EBM use and medication possession ratio among users. RESULTS: Of 9827 beneficiaries with CHF and systolic dysfunction, 24.2% had a diagnosis of ADRD. Beneficiaries with ADRD were older (80.8 vs 73.6 years; P < 0.0001) and more likely to be female (69.3% vs 58.1%; P < 0.0001). Overall EBM use was lower in patients with CHF and ADRD compared with patients with CHF but no ADRD (85.3% vs 91.2%; P < 0.0001). Lower use among those with ADRD was consistent across all EBM classes except vasodilators. Among beneficiaries receiving EBM, those with ADRD had a slightly higher mean medication possession ratio for EBM compared with those without ADRD (0.86 vs 0.84; P = 0.0001). CONCLUSIONS: EBM medication adherence was high in this population, regardless of ADRD status. However, patients with ADRD had lower EBM use compared with those without ADRD. Low use of specific EBM medications such as β-blockers was found in both groups. Therefore, interventions targeting increased treatment with specific EBMs for CHF, even among patients with ADRD, may be of benefit and could help reduce CHF-related hospitalizations.
Medication adherence among geriatric outpatients prescribed multiple medications.
Tsai KT, Chen JH, Wen CJ … +5 more , Kuo HK, Lu IS, Chiu LS, Wu SC, Chan DC
Am J Geriatr Pharmacother · 2012 Feb · PMID 22264853 · Publisher ↗
BACKGROUND: Poor medication adherence (PMA) is associated with higher risks of morbidity, hospitalization, and mortality. Polypharmacy is not only a determinant of PMA but is also associated with many adverse health outc...
BACKGROUND: Poor medication adherence (PMA) is associated with higher risks of morbidity, hospitalization, and mortality. Polypharmacy is not only a determinant of PMA but is also associated with many adverse health outcomes. OBJECTIVE: We aimed to determine the prevalence and correlates of PMA in an older population with polypharmacy. METHODS: Baseline data from 193 older adults from the Medication Safety Review Clinic Taiwan Study were analyzed. Patients were either prescribed ≥8 long-term medications or visited ≥3 different physicians between August and October 2007. PMA was defined as taking either <80% or >120% of prescribed amounts of a medication. Patients were classified as no (0%), low level (>0 but <25%), and high level (≥25%) PMA depending on what percentage of entire medication regimen taken reached PMA. RESULTS: Mean (SD) age was 76 (6) years, and mean number of medications was 9 (3), with a mean medication class number of 4 (1). Of the 1713 medications reviewed, 19% had PMA. However, at patient level, 34%, 32%, and 34% of patients were classified as no, low level, and high level PMA, respectively. Correlates varied by levels of PMA. Compared with patients without PMA, higher medication class number and use of alimentary tract, psychotropic, and hematologic agents were associated with both low and high level PMA. History of dizziness was associated with low level PMA, and higher Mini Mental Status Examination score was associated with high level PMA. CONCLUSIONS: To enhance medication adherence in older adults prescribed multiple medications, medication class numbers and certain high-risk medication classes should be taken into account. Physicians should also routinely assess systemic (eg, cognition) or drug-specific characteristics (eg, side effects).
Tolerability of topical diclofenac sodium 1% gel for osteoarthritis in seniors and patients with comorbidities.
Baraf HS, Gold MS, Petruschke RA … +1 more , Wieman MS
Am J Geriatr Pharmacother · 2012 Feb · PMID 22264852 · Publisher ↗
BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with a dose-related risk of cardiovascular, renal, and gastrointestinal adverse events (AEs). Topical NSAIDs produce lower systemic NSAID exposure...
BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with a dose-related risk of cardiovascular, renal, and gastrointestinal adverse events (AEs). Topical NSAIDs produce lower systemic NSAID exposure compared with oral NSAIDs, offering potential benefits. OBJECTIVE: To evaluate the safety of topical diclofenac sodium 1% gel (DSG) for knee and hand osteoarthritis (OA) in older and younger patients and in patients with versus without comorbid hypertension, type 2 diabetes, or cerebrovascular or cardiovascular disease. METHODS: Post hoc analysis of pooled data from 5 randomized, double-blind, placebo-controlled trials involving 1426 patients (aged ≥35 years) with mild to moderate OA of the knee and 783 patients (aged ≥40 years) with mild to moderate OA of the hand. Patients applied 4 g of DSG or vehicle to affected knees QID for 12 weeks or 2 g of DSG or vehicle to affected hands QID for 8 weeks. RESULTS: In patients with knee OA, the percentage with ≥1 adverse event was similar in patients aged <65 years (56.6%) versus ≥65 years (55.8%) and was similar in patients with versus without comorbid hypertension (53.4% vs 59.0%, respectively), type 2 diabetes mellitus (50.0% vs 57.2%), or cerebrovascular or cardiovascular disease (53.8% vs 56.5%). In patients with hand OA, the percentage with ≥1 AE was similar in patients aged ≥65 years (42.7%) versus <65 years (39.1%) and was similar in patients with versus without hypertension (39.6% vs 41.7%, respectively), lower in patients with versus without type 2 diabetes mellitus (28.0% vs 41.6%), and higher in patients with versus without cerebrovascular or cardiovascular disease (48.5% vs 39.2%). Gastrointestinal, cardiovascular, and renal AEs were rare and did not differ according to age or comorbidity. Application site reactions were the primary cause for the greater frequency of AEs with DSG versus vehicle. CONCLUSION: The similar and low rates of AEs in DSG-treated patients aged ≥65 years and <65 years and in those with and without comorbid hypertension, type 2 diabetes, or cerebrovascular or cardiovascular disease suggest that DSG treatment is generally well tolerated.
Clostridium difficile infection in older adults: a review and update on its management.
Kee VR
Am J Geriatr Pharmacother · 2012 Feb · PMID 22260856 · Publisher ↗
BACKGROUND: Clostridium difficile is a main cause of health care-associated infections. The incidence and severity have been increasing. Elderly persons are at an increased risk of morbidity and mortality from C. diffici...
BACKGROUND: Clostridium difficile is a main cause of health care-associated infections. The incidence and severity have been increasing. Elderly persons are at an increased risk of morbidity and mortality from C. difficile infection (CDI). Relatively few advances have been made in the treatment of CDI since it was first identified as a cause of antibiotic-associated diarrhea more than 30 years ago. OBJECTIVE: This article reviews CDI and provides an update on its treatment, including recently published clinical practice guidelines and the recently approved drug, fidaxomicin. METHODS: English-language literature was identified through a search of PubMed (1966-October 2011), Iowa Drug Information Service (1966-October 2011), and International Pharmaceutical Abstracts (1970-October 2011). Key search terms included Clostridium difficile, Clostridium infections, pseudomembranous colitis, antibiotic-associated diarrhea, Clostridium difficile-associated diarrhea, elderly, geriatric, epidemiology, microbiology, diagnosis, risk factors, treatment, drug therapy, vancomycin, metronidazole, and fidaxomicin. RESULTS: Metronidazole and vancomycin remain the mainstays of CDI treatment. Current guidelines recommend oral metronidazole for initial mild to moderate episodes or first recurrence. Oral vancomycin is recommended for initial severe episodes, or first or second recurrence. Fidaxomicin was approved in 2011 for treatment of CDI, but its place in therapy has yet to be determined. Other antibiotics have been used with variable success. Saccharomyces boulardii is the only probiotic that has shown efficacy in CDI. Fecal transplants have been used successfully in some patients, but randomized studies are needed. Immune therapy with a vaccine and monoclonal antibodies is being studied in clinical trials. CONCLUSIONS: Treatment of CDI is challenging due to the limited number of drugs that have proven to be effective, concerns about antibiotic resistance, and recurring disease. The recent approval of fidaxomicin provides a new alternative. Immune therapy will likely play a greater role in the future.
About
- Frequency
- Sun
- Papers found
- 200
- RSS feed
- Subscribe