The American Journal Of Geriatric Pharmacotherapy[JOURNAL]
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200 papers
Warfarin use in nursing home residents: results from the 2004 national nursing home survey.
Ghaswalla PK, Harpe SE, Slattum PW
Am J Geriatr Pharmacother · 2012 Feb · PMID 22226690 · Publisher ↗
BACKGROUND: Practice guidelines recommend anticoagulation therapy with warfarin for stroke prevention in patients with atrial fibrillation (AF). Despite this, warfarin is underused in older adults. OBJECTIVE: The purpose...
BACKGROUND: Practice guidelines recommend anticoagulation therapy with warfarin for stroke prevention in patients with atrial fibrillation (AF). Despite this, warfarin is underused in older adults. OBJECTIVE: The purpose of this study was to determine the prevalence of AF in nursing home (NH) residents and the use of warfarin or other antiplatelet medications in NH residents with AF who have indications for and no contraindications against warfarin use. The secondary objective was to determine the factors associated with warfarin use in NH residents with AF. METHODS: Cross-sectional analysis of prescription and resident data files from the 2004 National Nursing Home Survey was performed. Residents with a diagnosis of AF were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, and prescriptions of warfarin and antiplatelet medications were identified using Long-Term Care Drug Database System (LTCDDS) codes. Resident characteristics, stroke risk factors, and potential bleeding risk factors significant at P < 0.10 in χ(2) analyses were entered in the final multiple logistic regression model to determine the factors associated with warfarin use. RESULTS: From 13,507 NH residents, 1904 (14%) had a diagnosis of AF and 1767 (13%) had a diagnosis of AF with indications for and no contraindications against warfarin use. Of these 1767 residents, 537 (30%) were prescribed warfarin, and of the remaining 1230 residents who were not prescribed warfarin, 283 (23%) received either aspirin or clopidogrel. Thus, of 1767 residents with AF, with indications for and no contraindications to warfarin use, 947 (54%) residents did not receive any antithrombotic therapy in the form of warfarin, aspirin, clopidogrel, or a combination of these medications. Factors that were significantly associated with increased odds of receiving warfarin were congestive heart failure, previous stroke or transient ischemic attack, deep vein thrombosis or peripheral embolus, valvular heart disease, and total number of medications ≥ 6. Factors that were significantly associated with reduced odds of receiving warfarin were nonwhite race, history of gastrointestinal bleeding, and use of antiplatelets (ie, clopidogrel). CONCLUSIONS: AF is common in NH residents, and more than half of the residents with AF who had indications for and no contraindications against warfarin use were not prescribed either warfarin or antiplatelets, such as aspirin or clopidogrel, suggesting that antithrombotic therapy may be underused in NH residents with AF.
How important are drug-drug interactions to the health of older adults?
Hanlon JT, Schmader KE
Am J Geriatr Pharmacother · 2011 Dec · PMID 22088796 · Publisher ↗
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Potentially harmful drug-drug interactions in the elderly: a review.
Hines LE, Murphy JE
Am J Geriatr Pharmacother · 2011 Dec · PMID 22078863 · Publisher ↗
BACKGROUND: Elderly patients are vulnerable to drug interactions because of age-related physiologic changes, an increased risk for disease associated with aging, and the consequent increase in medication use. OBJECTIVE:...
BACKGROUND: Elderly patients are vulnerable to drug interactions because of age-related physiologic changes, an increased risk for disease associated with aging, and the consequent increase in medication use. OBJECTIVE: The purpose of this narrative review was to describe findings from rigorously designed observational cohort and case-control studies that have assessed specific drug interactions in elderly patients. METHODS: The PubMed and International Pharmaceutical Abstracts databases were searched for studies published in English over the past 10 years (December 2000-December 2010) using relevant Medical Subject Headings terms (aged; aged, 80 and over; and drug interactions) and search terms (drug interaction and elderly). Search strategies were saved and repeated through September 2011 to ensure that the most recent relevant published articles were identified. Additional articles were found using a search of review articles and reference lists of the identified studies. Studies were included if they were observational cohort or case-control studies that reported specific adverse drug interactions, included patients aged ≥65 years, and evaluated clinically meaningful end points. Studies were excluded if they used less rigorous observational designs, assessed pharmacokinetic/pharmacodynamic properties, evaluated drug-nutrient or drug-disease interactions or interactions of drug combinations used for therapeutic benefit (eg, dual antiplatelet therapy), or had inconclusive evidence. RESULTS: Seventeen studies met the inclusion criteria. Sixteen studies reported an elevated risk for hospitalization in older adults associated with adverse drug interactions. The drug interactions included: angiotensin-converting enzyme (ACE) inhibitors and potassium-sparing diuretics, ACE inhibitors or angiotensin receptor blockers and sulfamethoxazole/trimethoprim, benzodiazepines or zolpidem and interacting medications, calcium channel blockers and macrolide antibiotics, digoxin and macrolide antibiotics, lithium and loop diuretics or ACE inhibitors, phenytoin and sulfamethoxazole/trimethoprim, sulfonylureas and antimicrobial agents, theophylline and ciprofloxacin, and warfarin and antimicrobial agents or nonsteroidal anti-inflammatory drugs. One study reported the risk for breast cancer-related death as a function of paroxetine exposure among women treated with tamoxifen. CONCLUSIONS: Several population-based studies have reported significant harm associated drug interactions in elderly patients. Increased awareness and interventions aimed at reducing exposure and minimizing the risks associated with potentially harmful drug combinations are needed.
Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.
Desai R, Williams CE, Greene SB … +2 more , Pierson S, Hansen RA
Am J Geriatr Pharmacother · 2011 Dec · PMID 22078862 · Publisher ↗
BACKGROUND: Patients transitioning to a nursing home from their home or other facility are at high risk for medication errors. OBJECTIVE: Our aim was to describe characteristics of medication errors occurring during tran...
BACKGROUND: Patients transitioning to a nursing home from their home or other facility are at high risk for medication errors. OBJECTIVE: Our aim was to describe characteristics of medication errors occurring during transitions to nursing homes, to compare characteristics of transition errors with errors not involving a transition, and to evaluate the impact of these errors on patient harm. METHODS: This was a cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative during fiscal years 2007 through 2009. Bivariate associations between errors in transition with patient factors, error-related factors, reported causes of errors, and impact on patients were tested using a χ(2) test. Multivariate logistic regression explored whether medication errors during transitions were more harmful than errors not occurring during transitions. Patient-related factors included in the model were age, sex, and cognitive ability. Error-related factors were primary type of error, process phase when error began, primary personnel involved, and an indicator for repeat error. RESULTS: A total of 27,759 individual medication error incidents were reported over a 3-year period in North Carolina nursing homes. Of these errors, 2919 incidents (11%) involved a patient transitioning to a nursing home. Errors involved in transitions were found to have higher odds of patient harm compared with errors not involved in transitions (odds ratio = 1.85; 95% CI, 1.30-2.63). Staff communication, order transcription, medication availability, pharmacy issues, and name confusion were particularly important contributors to medication errors during transitions (P < 0.05 for comparison with nontransition errors). CONCLUSIONS: Transitions across care settings introduce risk for patient harm, and medication errors are an important area for improvement during transitions.
Medication use and functional status decline in older adults: a narrative review.
Peron EP, Gray SL, Hanlon JT
Am J Geriatr Pharmacother · 2011 Dec · PMID 22057096 · Full text
BACKGROUND: Functional status is the cornerstone of geriatric care and serves as an indicator of general well-being. A decline in function can increase health care use, worsen quality of life, threaten independence, and...
BACKGROUND: Functional status is the cornerstone of geriatric care and serves as an indicator of general well-being. A decline in function can increase health care use, worsen quality of life, threaten independence, and increase the risk of mortality. One of several risk factors for decline in functional status is medication use. OBJECTIVE: Our aim was to critically review published articles that have examined the relationship between medication use and functional status decline in the elderly. METHODS: The MEDLINE and EMBASE databases were searched for English-language articles published from January 1986 to June 2011. Search terms included aged, humans, drug utilization, polypharmacy, inappropriate prescribing, anticholinergics, psychotropics, antihypertensives, drug burden index, functional status, function change or decline, activities of daily living, gait, mobility limitation, and disability. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to retrieve additional publications. Only articles that used rigorous observational or interventional designs were included. Cross-sectional studies and case series were excluded from this review. RESULTS: Nineteen studies met the inclusion criteria. Five studies addressed the impact of suboptimal prescribing on function, 3 of which found an increased risk of worse function in community-dwelling subjects receiving polypharmacy. Three of the 4 studies that assessed benzodiazepine use and functional status decline found a statistically significant association. One cohort study identified no relationship between antidepressant use and functional status, whereas a randomized trial found that amitriptyline, but not desipramine or paroxetine, impaired certain measures of gait. Two studies found that increasing anticholinergic burden was associated with worse functional status. In a study of hospitalized rehabilitation patients, users of hypnotics/anxiolytics (eg, phenobarbital, zolpidem) had lower relative Functional Independence Measure motor gains than nonusers. Use of multiple central nervous system (CNS) drugs (using different definitions) was linked to greater declines in self-reported mobility and Short Physical Performance Battery (SPPB) scores in 2 community-based studies. Another study of nursing home patients did not report a significant decrease in SPPB scores in those taking multiple CNS drugs. Finally, 2 studies found mixed effects between antihypertensive use and functional status in the elderly. CONCLUSIONS: Benzodiazepines and anticholinergics have been consistently associated with impairments in functional status in the elderly. The relationships between suboptimal prescribing, antidepressants, and antihypertensives and functional status decline were mixed. Further research using established measures and methods is needed to better describe the impact of medication use on functional status in older adults.
Comparison of the efficacy and tolerability profile of liraglutide, a once-daily human GLP-1 analog, in patients with type 2 diabetes ≥65 and <65 years of age: a pooled analysis from phase III studies.
Bode BW, Brett J, Falahati A … +1 more , Pratley RE
Am J Geriatr Pharmacother · 2011 Dec · PMID 22055210 · Publisher ↗
BACKGROUND: Managing elderly patients with type 2 diabetes poses particular challenges, so it is important to evaluate the efficacy and tolerability profile of antidiabetic therapies specifically in this patient populati...
BACKGROUND: Managing elderly patients with type 2 diabetes poses particular challenges, so it is important to evaluate the efficacy and tolerability profile of antidiabetic therapies specifically in this patient population. OBJECTIVE: The aim of our study was to compare the efficacy and tolerability profile of liraglutide, a GLP-1 analog, in elderly (≥65 years) and younger (<65 years) patients with type 2 diabetes. METHODS: A pooled analysis of 6 randomized, placebo-controlled, multinational trials included data from 3967 patients aged18 to 80 years with type 2 diabetes and glycosylated hemoglobin (HbA(1c)) of 7% to 11%. Of these, 552 patients ≥65 years received liraglutide 1.8 mg, liraglutide 1.2 mg, or placebo; 2231 patients <65 years received liraglutide 1.8 mg, liraglutide 1.2 mg, or placebo for 26 weeks. End points were: change in HbA(1c), fasting plasma glucose, body weight, and blood pressure: as marked to identify elements tracked for change from baseline; hypoglycemic episodes; and adverse events. RESULTS: Reduction in HbA(1c) from baseline was significantly greater with liraglutide 1.8 mg versus placebo (least squares mean difference: ≥65 years, 0.91% [95% CI, 0.69-1.12]; <65 years, 1.17% [95% CI, 1.06-1.28]; both, P < 0.0001) and with liraglutide 1.2 mg versus placebo (≥65 years, 0.87% [95% CI, 0.64-1.11]; <65 years, 1.10% [95% CI, 0.98-1.22]; both, P < 0.0001). For fasting plasma glucose, comparable results were observed between liraglutide 1.8 mg or 1.2 mg and placebo for both age groups (P < 0.0001). No statistically significant difference in body weight change was seen with liraglutide between the age groups. The proportion of patients reporting minor hypoglycemia was low and appeared comparable between the ≥65-year-old (4.3%-15.2%) and <65-year-old (8%-13.2%) groups. Likewise, adverse events appeared comparable in nature and frequency. CONCLUSION: Liraglutide provides effective glycemic control and is well tolerated in patients ≥65 and <65 years of age with type 2 diabetes. These data suggest that liraglutide may be a suitable treatment option for older patients who may have additional age-related complications.
Development and testing of a tool for assessing and resolving medication-related problems in older adults in an ambulatory care setting: the individualized medication assessment and planning (iMAP) tool.
Crisp GD, Burkhart JI, Esserman DA … +2 more , Weinberger M, Roth MT
Am J Geriatr Pharmacother · 2011 Dec · PMID 22055209 · Full text
BACKGROUND: Medication is one of the most important interventions for improving the health of older adults, yet it has great potential for causing harm. Clinical pharmacists are well positioned to engage in medication as...
BACKGROUND: Medication is one of the most important interventions for improving the health of older adults, yet it has great potential for causing harm. Clinical pharmacists are well positioned to engage in medication assessment and planning. The Individualized Medication Assessment and Planning (iMAP) tool was developed to aid clinical pharmacists in documenting medication-related problems (MRPs) and associated recommendations. OBJECTIVE: The purpose of our study was to assess the reliability and usability of the iMAP tool in classifying MRPs and associated recommendations in older adults in the ambulatory care setting. METHODS: Three cases, representative of older adults seen in an outpatient setting, were developed. Pilot testing was conducted and a "gold standard" key developed. Eight eligible pharmacists consented to participate in the study. They were instructed to read each case, make an assessment of MRPs, formulate a plan, and document the information using the iMAP tool. Inter-rater reliability was assessed for each case, comparing the pharmacists' identified MRPs and recommendations to the gold standard. Consistency of categorization across reviewers was assessed using the κ statistic or percent agreement. RESULTS: The mean κ across the 8 pharmacists in classifying MRPs compared with the gold standard was 0.74 (range, 0.54-1.00) for case 1 and 0.68 (range, 0.36-1.00) for case 2, indicating substantial agreement. For case 3, percent agreement was 63% (range, 40%-100%). The mean κ across the 8 pharmacists when classifying recommendations compared with the gold standard was 0.87 (range, 0.58-1.00) for case 1 and 0.88 (range, 0.75-1.00) for case 2, indicating almost perfect agreement. For case 3, percent agreement was 68% (range, 40%-100%). Clinical pharmacists found the iMAP tool easy to use. CONCLUSIONS: The iMAP tool provides a reliable and standardized approach for clinical pharmacists to use in the ambulatory care setting to classify MRPs and associated recommendations. Future studies will explore the predictive validity of the tool on clinical outcomes such as health care utilization.
Impact of a multidisciplinary intervention on antibiotic use for nursing home-acquired pneumonia.
Linnebur SA, Fish DN, Ruscin JM … +8 more , Radcliff TA, Oman KS, Fink R, Van Dorsten B, Liebrecht D, Fish R, McNulty M, Hutt E
Am J Geriatr Pharmacother · 2011 Dec · PMID 22055208 · Publisher ↗
BACKGROUND: Academic detailing in nursing homes (NHs) has been shown to improve drug use patterns and adherence to guidelines. OBJECTIVE: The purpose of this study was to evaluate the impact of a multidisciplinary interv...
BACKGROUND: Academic detailing in nursing homes (NHs) has been shown to improve drug use patterns and adherence to guidelines. OBJECTIVE: The purpose of this study was to evaluate the impact of a multidisciplinary intervention that included academic detailing on adherence to national nursing home-acquired pneumonia (NHAP) guidelines related to use of antibiotics. METHODS: This quasi-experimental study evaluated the effects of a 2-year multifaceted and multidisciplinary intervention targeting implementation of national evidence-based guidelines for NHAP. Interventions took place in 8 NHs in Colorado; 8 NHs in Kansas and Missouri served as controls. Interventions included (1) educational sessions for nurses to improve recognition and timely treatment of NHAP symptoms and (2) academic detailing to clinicians by pharmacists regarding diagnostic and prescribing practices. Differences in antibiotic use between groups were compared after 2 intervention years relative to baseline. RESULTS: A total of 549 episodes of NHAP were evaluated in the intervention group and 574 in the control group. Compared with baseline, 1 facility in the intervention group significantly improved in guideline adherence for optimal antibiotic use (P = 0.007), whereas no facilities in the control group improved. The mean adherence score for optimal antibiotic use in intervention NHs increased from 60% to 66%, whereas the control NHs increased from 32% to 39% (P = 0.3). Mean adherence to guidelines recommending antibiotic use within 4 hours of NHAP diagnosis increased from 57% to 75% in intervention NHs but decreased from 38% to 31% in control NHs (P = 0.0003 for difference). There was no difference between intervention and control NHs for guideline adherence regarding optimal duration of antibiotic use. CONCLUSIONS: The ability of this multifaceted study to repeatedly remind nursing staff of the importance of timely antibiotic administration contrasts with its limited academic detailing interaction with clinicians. This difference within the intervention may explain the differential impact of the intervention on antibiotic guideline adherence.
Streptococcus pneumoniae vaccination in older adults.
Rightmier E, Stevens V, Brown J
Am J Geriatr Pharmacother · 2011 Dec · PMID 22047941 · Publisher ↗
BACKGROUND: Streptococcus pneumoniae infections are a major cause of morbidity and mortality in older adults. Vaccination in older adults is intended to prevent S pneumoniae infections, yet little information is availabl...
BACKGROUND: Streptococcus pneumoniae infections are a major cause of morbidity and mortality in older adults. Vaccination in older adults is intended to prevent S pneumoniae infections, yet little information is available regarding its efficacy in this patient population. OBJECTIVE: The aim of this article was to review the current literature to determine the efficacy and tolerability of S pneumoniae vaccination in older adults. METHODS: PubMed (1950-present) and EMBASE (1974-present) were searched using the search terms Streptococcus pneumoniae immunization, pneumococcus immunization, pneumococcus vaccine, and aged. Additional articles were identified from the reference lists of included studies. Studies were included if they reported information in older (55-<65 years) and elderly (≥65 years) adults and were related to at least 1 of the following topics: epidemiology of S pneumoniae, estimates of vaccine coverage, recommendations for vaccination, tolerability, and efficacy and/or effectiveness of vaccination against S pneumoniae. RESULTS: Six randomized controlled trials and 18 observational studies that evaluated the efficacy of pneumococcal vaccination in older and elderly adults were reviewed. Findings from evaluations of efficacy, as measured by clinical outcomes and immunogenicity, in older adults have been conflicting, with some subsets of prospective, well-controlled studies finding little benefit, whereas findings from several retrospective studies have suggested significant benefit. This discord may have been a result of the limited power of the prospective subanalyses to detect significant differences. CONCLUSIONS: In light of the potential clinical benefit and few reports of serious adverse events, vaccination in older adults is likely warranted. Prospective, well-controlled studies are needed to better quantitatively evaluate the benefit of pneumococcal vaccine in older adults.
Trajectory classes of depression in a randomized depression trial of heart failure patients: a reanalysis of the SADHART-CHF trial.
Kuchibhatla MN, Fillenbaum GG
Am J Geriatr Pharmacother · 2011 Dec · PMID 22035643 · Full text
OBJECTIVE: The objective of this article was to determine whether, in drug intervention trials, growth mixture modeling (GMM) is able to identify drug-responsive trajectory classes that are not evident in traditional gro...
OBJECTIVE: The objective of this article was to determine whether, in drug intervention trials, growth mixture modeling (GMM) is able to identify drug-responsive trajectory classes that are not evident in traditional growth modeling approaches. METHODS: We reanalyzed acute phase (biweekly data up to 7 occasions) and longitudinal (12 months) data on the 469 patients in the SADHART-CHF study of the safety and efficacy of sertraline for depression in patients with heart failure. GMM was used to identify the trajectory classes present in the treatment and placebo groups, based on Hamilton Depression Rating Scale scores. RESULTS: Two distinct trajectory classes were identified in the treatment group: (1) chronic depressives (12%), who remained depressed through the treatment phase; and (2) responders (88%), who had scores indicating nondepression at the conclusion of the acute phase. At baseline, chronic depressives were distinguished by higher Hamilton Depression Rating Scale scores, the presence of implantable cardioverter defibrillators, and a history of anxiety. During follow-up, they were more likely to have unstable angina. Only responders remitted (70%). Three distinct trajectories were identified in the placebo group: (1) moderating depressives (19%), (2) temporary improvers (13%), and (3) responders (68%). At baseline, the classes differed in mean Hamilton Depression Rating Scale scores, responders' scores falling between the other 2 classes, and the proportion with renal disease. Only remission differed at follow-up: responders (76%), moderating depressives (21%), and temporary improvers (3%). Where the traditional analytic approach found improvement from moderate to mild depression but no significant treatment effect, GMM found response in 20% more people in the treatment group than in the placebo group. CONCLUSIONS: Unlike conventionally used, standard analytic approaches, which focus on intervention impact at study end or change from baseline to study end, GMM enables maximum use of repeated data to identify unique trajectories of latent classes that are responsive to the intervention.
Prevalence and predictors of anticholinergic agents in elderly outpatients with dementia.
Bhattacharya R, Chatterjee S, Carnahan RM … +1 more , Aparasu RR
Am J Geriatr Pharmacother · 2011 Dec · PMID 22030114 · Publisher ↗
BACKGROUND: Anticholinergic medications, although frequently used in elderly populations, are associated with cognitive impairment and constitute significant concern for patients with dementia. OBJECTIVE: The purpose of...
BACKGROUND: Anticholinergic medications, although frequently used in elderly populations, are associated with cognitive impairment and constitute significant concern for patients with dementia. OBJECTIVE: The purpose of our study was to examine patterns and predictors of prescribing anticholinergic agents for elderly outpatients with dementia. METHODS: We combined data from the 2006-2007 National Ambulatory Medical Care Survey and the outpatient department component of National Hospital Ambulatory Medical Care Survey to analyze patient visits by elderly persons (aged ≥65 years) with dementia. Anticholinergic drugs were identified using the Anticholinergic Drug Scale, which classifies anticholinergic drugs into four levels (0-3) in increasing order of anticholinergic activity. Descriptive analysis using sampling weights was used to evaluate patterns of anticholinergic drug prescription, especially prescribing of medications with clinically significant anticholinergic activity (ie, levels 2 or 3). Multiple logistic regression was used in the conceptual framework of the Andersen Behavioral Model to examine the predisposing, enabling, and need factors associated with prescribing of medications with clinically significant anticholinergic activity. RESULTS: According to the national surveys there were a total of 6.8 million (95% CI, 5.27-8.44 million; 0.32%) ambulatory care visits for dementia. Approximately 43% (42.86%; 95% CI, 35.24-50.48) of these visits involved prescribing at least one anticholinergic drug; and 10.07% of visits involved prescribing levels 2 or 3 anticholinergic medications. The predisposing factor, age (75-84 years; odds ratio [OR] = 0.25; 95% CI, 0.07-0.87), and the need factors, acetylcholinesterase inhibitor use (OR = 0.25; 95% CI, 0.07-0.86) and comorbid mood disorders (OR = 0.12; 95% CI, 0.02-0.73), were associated with decreased likelihood of prescribing medications with clinically significant anticholinergic activity. The need factor total number of medications prescribed (OR = 1.45, 95% CI, 1.20-1.75) increased the likelihood of these prescriptions being administered. CONCLUSIONS: One in 10 outpatient visits by elderly persons with dementia involved prescribing medications with clinically significant anticholinergic activity. Given their adverse cognitive effects, there is a strong need to optimize anticholinergic drug prescribing in vulnerable elderly outpatients with dementia.
Detection and prevention of drug-drug interactions in the hospitalized elderly: utility of new cytochrome p450-based software.
Zakrzewski-Jakubiak H, Doan J, Lamoureux P … +3 more , Singh D, Turgeon J, Tannenbaum C
Am J Geriatr Pharmacother · 2011 Dec · PMID 22019006 · Publisher ↗
BACKGROUND: Polypharmacy increases the risk of cytochrome P450-based drug-drug interactions (CYP450-DDIs), leading to decreased therapeutic efficacy or increased drug toxicity. OBJECTIVE: The aims of this study were to i...
BACKGROUND: Polypharmacy increases the risk of cytochrome P450-based drug-drug interactions (CYP450-DDIs), leading to decreased therapeutic efficacy or increased drug toxicity. OBJECTIVE: The aims of this study were to investigate the utility of a new CYP450-DDI software, InterMED-Rx, in aiding pharmacists in detecting CYP450-DDIs in hospitalized elderly patients and to ascertain pharmacists' agreement on how to intervene for each CYP450-DDI. METHODS: A consensus panel of geriatric pharmacists first established guidelines for managing clinically relevant pharmacokinetic CYP450-DDIs. A prospective study was then conducted of patients newly admitted to a geriatric hospital whose pharmaceutical profile underwent analysis with InterMED-Rx. Rates and types of interventions were recorded. RESULTS: Pharmacists' interrater agreement on how to manage CYP450-DDIs was initially only moderate (Cohen's κ, 0.51; 95% CI, 0.39-0.62), but improved subsequent to deliberation (Cohen's κ, 0.79; 95% CI, 0.70-0.88). Persistent disagreement involved interactions between 2 drugs with similar affinities for the same cytochrome. One hundred patients with polypharmacy (≥5 medications) aged 82.3 years (range, 65-96), with a mean (SD) of 12.2 (4.1) drugs (range, 5-27) were recruited for the prospective study. Eighty percent of patients had at least 1 CYP450 DDI detected with InterMED-Rx. A total of 238 CYP450-DDIs were identified involving CYP3A4 (70.2%), CYP2D6 (22.7%), and CYP2C9 (3.4%) substrates or inhibitors. Nineteen percent of patients received immediate medication adjustment, and 39% required follow-up of clinical signs, symptoms, and laboratory tests to determine whether future modification was needed. More than one half (56%) of all patients who required clinical follow-up had further medication adjustment prior to discharge. CONCLUSIONS: Use of the InterMED-Rx software identified elderly patients at risk for pharmacokinetic interactions and facilitated interventions aimed at reducing adverse drug events. Although consensus can be reached among pharmacists on how to intervene for many CYP450-DDI scenarios, certain situations allow for multiple intervention strategies.
Drug utilization patterns and cardiovascular outcomes in elderly patients newly initiated on atorvastatin or simvastatin.
Swindle JP, Potash J, Kulakodlu M … +2 more , Kuznik A, Buikema A
Am J Geriatr Pharmacother · 2011 Dec · PMID 22019005 · Publisher ↗
BACKGROUND: Hydroxymethylglutaryl coenzyme-A reductase inhibitors simvastatin and atorvastatin are effective at lowering LDL-C levels and reducing the risk of cardiovascular (CV) events. OBJECTIVE: The objective of this...
BACKGROUND: Hydroxymethylglutaryl coenzyme-A reductase inhibitors simvastatin and atorvastatin are effective at lowering LDL-C levels and reducing the risk of cardiovascular (CV) events. OBJECTIVE: The objective of this study was to examine differences in drug utilization and CV event risk among elderly patients newly initiated on simvastatin versus atorvastatin. METHODS: This was a retrospective analysis using pharmacy and medical claims from a US health plan database. Enrollees aged ≥65 years, newly initiated on simvastatin or atorvastatin (index drugs) from July 1, 2006 to November 30, 2008 were identified for study inclusion. Patients were excluded if they had any prescriptions for clopidogrel, nitrates, or other dyslipidemia medication, or any CV events before index drug initiation. Adherence was calculated by proportion of days covered with index medication. CV events (myocardial infarction, ischemic heart disease, cerebrovascular disease, peripheral vascular disease, aortic aneurysm, revascularization, or heart failure) were identified from medical claims. RESULTS: There were 11,470 atorvastatin initiators and 20,132 simvastatin initiators identified. Mean age of these patients was 72 years; 40% were male; nearly half had hypertension; and more than a quarter had diabetes. The majority of statin therapy (77%) was prescribed by primary care physicians. Forty-nine percent of atorvastatin patients were initiated on a 10 mg-dose and 61% of simvastatin patients on 5-, 10-, or 20-mg doses. A larger percentage of patients in the simvastatin cohort were adherent to index therapy than patients in the atorvastatin cohort (43% vs 36%, respectively). Multivariate regression adjusting for patient characteristics revealed no significant difference in CV events between patients receiving atorvastatin versus simvastatin. CONCLUSIONS: In this study of elderly statin patients without recent evidence of CV events, the majority of patients started on low-dose therapy and did not achieve sufficient adherence. After controlling for patient and clinical characteristics, no statistically significant difference in risk of CV event was observed based on initiation with atorvastatin versus simvastatin.
Valproic acid-induced parkinsonism in the elderly: a comprehensive review of the literature.
Mahmoud F, Tampi RR
Am J Geriatr Pharmacother · 2011 Dec · PMID 21993183 · Publisher ↗
BACKGROUND: Valproic acid (VPA) is commonly used to treat many psychiatric conditions in the elderly. VPA-induced parkinsonism is a less common but important adverse effect of this drug. OBJECTIVES: The purpose of our st...
BACKGROUND: Valproic acid (VPA) is commonly used to treat many psychiatric conditions in the elderly. VPA-induced parkinsonism is a less common but important adverse effect of this drug. OBJECTIVES: The purpose of our study was to conduct a literature review to assess VPA-induced parkinsonism in the elderly. METHODS: We searched Ovid Medline, PubMed, and Cochrane Database (January 1970 to December 2010) using the key words divalproate, divalproex sodium, valproate, depakote, valproic acid, elderly, aged, Parkinson's disease, and parkinsonism. The Naranjo algorithm was used to assess whether a change in clinical status was the result of an adverse drug reaction. RESULTS: We identified 13 case reports. Available evidence indicated that there was a variable time interval for the development of parkinsonism after VPA therapy. Most cases showed improvement with the withdrawal of the drug, but the rate and extent of improvement was unpredictable. The calculated Naranjo adverse drug reaction scores, for most cases, were between 5 and 6, meaning it was probable that parkinsonism was due to VPA therapy. CONCLUSIONS: High clinical awareness is required in diagnosing VPA-induced parkinsonism in the elderly due the presence of comorbid neurodegenerative conditions and the usage of antipsychotics in these patients.
Successful reintroduction of valproic acid after the occurrence of pancytopenia.
Stewart JT
Am J Geriatr Pharmacother · 2011 Oct · PMID 21962938 · Publisher ↗
BACKGROUND: Valproic acid is associated with a variety of hematologic abnormalities, most commonly thrombocytopenia. Pancytopenia is much less common and potentially much more serious. Little is known about the natural c...
BACKGROUND: Valproic acid is associated with a variety of hematologic abnormalities, most commonly thrombocytopenia. Pancytopenia is much less common and potentially much more serious. Little is known about the natural course of valproate-induced pancytopenia. CASE SUMMARY: We present a patient who developed pancytopenia while taking valproic acid for bipolar illness. After failing to respond to several other mood stabilizers, valproic acid was cautiously reintroduced with close hematologic monitoring. The pancytopenia has not recurred in the past 6 months. CONCLUSIONS: Pancytopenia may not represent an absolute contraindication to continuing valproate therapy, although caution is warranted.
Discontinuation of acetylcholinesterase inhibitor treatment in the nursing home.
Mansour D, Wong R, Kuskowski M … +1 more , Dysken M
Am J Geriatr Pharmacother · 2011 Oct · PMID 21925960 · Publisher ↗
BACKGROUND: Dementia treatment guidelines are not consistent in determining how long to continue acetylcholinesterase inhibitor (AChEI) treatment in patients with Alzheimer's disease. OBJECTIVE: Our aim was to examine re...
BACKGROUND: Dementia treatment guidelines are not consistent in determining how long to continue acetylcholinesterase inhibitor (AChEI) treatment in patients with Alzheimer's disease. OBJECTIVE: Our aim was to examine reasons for AChEI discontinuation in a nursing home to better understand how practitioners actually decide when to stop treatment. METHODS: A retrospective chart review was done on 107 deceased nursing home veterans who had been taking an AChEI to determine the time between discontinuation and death. RESULTS: In the majority of residents (n = 67; 63%), the AChEI was continued into the week preceding death. Reasons for discontinuation were dying or death (n = 56; 52%), admission to hospice (n = 13; 12.2%), and admission to the nursing home (n = 5; 4.7%). Admission to hospice (P = 0.01), hospice length of stay (P = 0.0004), and length of stay at Minnesota Veterans Home (P = 0.02) were significantly associated with discontinuation of AchEI before the last week of life. CONCLUSION: Our study showed that residents were significantly more likely to have their AChEI discontinued if they were either admitted to hospice, stayed longer in hospice, or stayed longer in the nursing home. In addition, the majority of residents continued AChEI treatment until sometime during the week before death occurred.
Implementation of a community pharmacy-based falls prevention program.
Casteel C, Blalock SJ, Ferreri S … +2 more , Roth MT, Demby KB
Am J Geriatr Pharmacother · 2011 Oct · PMID 21925959 · Publisher ↗
BACKGROUND: Falls are the leading cause of fatal and nonfatal unintentional injury among older adults in the United States. Multifaceted falls prevention programs, which have been reported to reduce the risk for falls am...
BACKGROUND: Falls are the leading cause of fatal and nonfatal unintentional injury among older adults in the United States. Multifaceted falls prevention programs, which have been reported to reduce the risk for falls among older adults, usually include a medication review and modification component. Based on a literature search, no randomized trials that have examined the effectiveness of this component have been published. OBJECTIVE: The aim of this article was to report on a retrospective process evaluation of data from a randomized, controlled trial conducted to examine the effectiveness of a medication review intervention, delivered through community pharmacies, on the rate of falls among community-dwelling older adults. METHODS: Patients were recruited through 32 pharmacies in North Carolina. Participants were community-dwelling older adults at high risk for falls based on age (≥ 65 years), number of concurrent medications (≥ 4), and medication classes (emphasis on CNS-active agents). The process evaluation measured the recruitment of patients into the study, the process through which the intervention was delivered, the extent to which patients implemented the recommendations for intervention, and the acceptance of pharmacists' recommendations by prescribing physicians. RESULTS: Of the 7793 patients contacted for study participation, 981 (12.6%) responded to the initial inquiry. A total of 801 (81.7%) participated in an eligibility interview, of whom 342 (42.7%) were eligible. Baseline data collection was completed in 186 of eligible patients (54.4%), who were randomly assigned to the intervention group (n = 93) or the control group (n = 93). Pharmacists delivered a medication review to 73 of the patients (78.5%) in the intervention group, with 41 recommendations for changes in medication, of which 10 (24.4%) were implemented. Of the 31 prescribing physicians contacted with pharmacists' recommendations, 14 (45.2%) responded, and 10 (32.3%) authorized the changes. CONCLUSIONS: Based on the findings from the present study, coordination of care between community pharmacists and prescribers needs to be improved for the realization of potential beneficial effects of medication management on falls prevention.
Transient impact of automated glomerular filtration rate reporting on drug dosing for hospitalized older adults with concealed renal insufficiency.
Kalender-Rich JL, Mahnken JD, Wetmore JB … +1 more , Rigler SK
Am J Geriatr Pharmacother · 2011 Oct · PMID 21920825 · Publisher ↗
BACKGROUND: Older adults with concealed renal insufficiency are at risk of medication dosing errors. It is not known whether automated estimated glomerular filtration rate (eGFR) reporting is associated with reduced dosi...
BACKGROUND: Older adults with concealed renal insufficiency are at risk of medication dosing errors. It is not known whether automated estimated glomerular filtration rate (eGFR) reporting is associated with reduced dosing errors in this population. OBJECTIVE: The goal of the present study was to examine the impact on prescribing patterns in older adults with concealed renal insufficiency for a variety of renally cleared medications before and after the addition of automated eGFR reporting. METHODS: We performed a retrospective chart review at a single tertiary academic medical center among hospitalized patients aged ≥ 70 years with concealed renal insufficiency. Data were examined from the months of July, December, and May before and after the hospital initiated automated eGFR reporting, in 2006-2007 and 2008-2009, respectively. Doses of selected renally cleared medications were classified as appropriate or inappropriate on the basis of published recommendations. Regression models were used to identify demographic, clinical, and care factors associated with dosing appropriateness. RESULTS: Before implementation of automated eGFR reporting, we observed 260 persons in whom 42.2% of relevant prescriptions were inappropriately dosed; after implementation, there were 280 subjects in whom 36.6% of relevant prescriptions were inappropriately dosed. The multivariable model suggested an overall trend toward less inappropriate dosing after automated eGFR reporting began, compared with rates before (adjusted odds ratio [AOR] = 0.75 [95% confidence interval: 0.52-1.07], P = 0.11). However, a gradient was observed as the academic year progressed. A marked reduction in the rate of inappropriate medication dosing was seen in July after initiation of eGFR reporting compared with the July before initiation (AOR = 0.28; P < 0.01). This effect was attenuated in December (AOR = 0.45; P = 0.05) and gone by May (AOR = 0.85; P = 0.67). CONCLUSION: Automated eGFR reporting alone, without any order entry intervention, was associated only transiently with improved dosing appropriateness for these older adults with concealed renal insufficiency.
Medication reconciliation: identifying medication discrepancies in acutely ill hospitalized older adults.
Villanyi D, Fok M, Wong RY
Am J Geriatr Pharmacother · 2011 Oct · PMID 21890424 · Publisher ↗
BACKGROUND: Medication discrepancies may occur during transitions from community to acute care hospitals. The elderly are at risk for such discrepancies due to multiple comorbidities and complex medication regimens. Medi...
BACKGROUND: Medication discrepancies may occur during transitions from community to acute care hospitals. The elderly are at risk for such discrepancies due to multiple comorbidities and complex medication regimens. Medication reconciliation involves verifying medication use and identifying and rectifying discrepancies. OBJECTIVE: The aim of this study was to describe the prevalences and types of medication discrepancies in acutely ill older patients. METHODS: Patients who were ≥ 70 years and were admitted to any of 3 acute care for elders (ACE) units over a period of 2 nonconsecutive months in 2008 were prospectively enrolled. Medication discrepancies were classified as intentional, undocumented intentional, and unintentional. Unintentional medication discrepancies were classified by a blinded rater for potential to harm. This study was primarily qualitative, and descriptive (univariate) statistics are presented. RESULTS: Sixty-seven patients (42 women; mean [SD] age, 84.0 [6.5] years) were enrolled. There were 37 unintentional prescription-medication discrepancies in 27 patients (40.3%) and 43 unintentional over-the-counter (OTC) medication discrepancies in 19 patients (28.4%), which translates to Medication Reconciliation Success Index (MRSI) of 89% for prescription medications and 59% for OTC medications. The overall MRSI was 83%. More than half of the prescription-medication discrepancies (56.8%) were classified as potentially causing moderate/severe discomfort or clinical deterioration. CONCLUSION: Despite a fairly high overall MRSI in these patients admitted to ACE units, a substantial proportion of the prescription-medication discrepancies were associated with potential harm.
Impact of telephone medication therapy management on medication and health-related problems, medication adherence, and Medicare Part D drug costs: a 6-month follow up.
Moczygemba LR, Barner JC, Lawson KA … +4 more , Brown CM, Gabrillo ER, Godley P, Johnsrud M
Am J Geriatr Pharmacother · 2011 Oct · PMID 21865093 · Publisher ↗
BACKGROUND: The Medicare Modernization Act of 2003 mandated the provision of medication therapy management (MTM) to eligible Part D beneficiaries to improve medication-related outcomes. As MTM programs evolve, evaluation...
BACKGROUND: The Medicare Modernization Act of 2003 mandated the provision of medication therapy management (MTM) to eligible Part D beneficiaries to improve medication-related outcomes. As MTM programs evolve, evaluation is necessary to help inform MTM best practices. OBJECTIVE: The objective of this study was to determine the impact of pharmacist-provided telephone MTM on: (1) medication and health-related problems (MHRPs); (2) medication adherence; and (3) Part D drug costs. METHODS: This quasi-experimental study included Part D beneficiaries from a Texas health plan. Andersen's Behavioral Model of Health Services Use served as the study framework. MTM utilization was the health behavior. Age, gender, and race were predisposing factors, and number of medications, chronic diseases, and medication regimen complexity were need factors. Outcomes were pre-to-post changes in: (1) MHRPs; (2) medication adherence, using the medication possession ratio (MPR); and (3) total drug costs. Multiple regression was used to analyze group differences while controlling for predisposing and need factors. RESULTS: At baseline, the intervention (n = 60) and control (n = 60) groups were not statistically different regarding predisposing and need factors, with the exception of gender. The intervention group had significantly (P = 0.009) more men compared with the control group (51.7% vs 28.3%). There were 4.8 (2.7) and 9.2 (2.9) MHRPs identified at baseline and 2.5 (2.0) and 7.9 (3.0) MHRPs remained at the 6-month follow up in the intervention and control groups, respectively. The intervention group (vs control) had significantly more MHRPs resolved (P = 0.0003). There were no significant predictors of change in MPR or total drug costs from baseline to follow up, although total drug costs decreased by $158 in the intervention group compared with a $118 increase in the control group. CONCLUSIONS: A telephone MTM program resolved significantly more MHRPs compared with a control group, but there were no significant changes in adherence and total drug costs.
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