The American Journal Of Geriatric Pharmacotherapy[JOURNAL]
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200 papers
Management of gout in the older adult.
Fravel MA, Ernst ME
Am J Geriatr Pharmacother · 2011 Oct · PMID 21849262 · Publisher ↗
BACKGROUND: Gout affects 3 million people in the United States, with rates almost 5 times higher in those aged 70 to 79 years compared with those aged < 50 years. Management of gout in elderly subjects can be complicated...
BACKGROUND: Gout affects 3 million people in the United States, with rates almost 5 times higher in those aged 70 to 79 years compared with those aged < 50 years. Management of gout in elderly subjects can be complicated by comorbidities and polypharmacy. OBJECTIVE: The purpose of this article was to review the unique clinical presentation, treatment, and prevention of gout in the older adult, with attention to the age-related factors that may affect outcomes in this population. METHODS: PubMed and the Iowa Drug Information Service were searched (1944-January 14, 2011) for clinical studies of gout using the following search terms: gout, elderly, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid, prednisone, prednisolone, methylprednisolone, triamcinolone, allopurinol, febuxostat, probenecid, sulfinpyrazone, uricosuric, fenofibrate, and losartan. Articles were limited to clinical trials in humans, published in English. Citations of these articles were analyzed for additional relevant studies, and current guidelines were also consulted. RESULTS: Twenty-nine citations were reviewed. Evidence suggests that colchicine, NSAIDs, and corticosteroids are all efficacious in the treatment of acute gout in the older adult. Relevant limitations to colchicine use in the older adult include high cost, dosing restrictions in severe renal and hepatic dysfunction, gastrointestinal intolerance, and potential drug interactions. NSAID therapy is not recommended in older patients with congestive heart failure, renal failure, or gastrointestinal problems. Corticosteroids pose little risk when used in the short-term and may be preferred in patients with contraindications to colchicine or NSAIDs. Urate lowering with allopurinol for prevention of gout is well tolerated and has minimal cost per month; however, dose reduction is recommended in patients with renal impairment, which often results in failure to achieve target serum urate concentrations. Febuxostat does not require dose adjustment in mild to moderate renal disease and may be preferred in older people with this condition. CONCLUSION: Management of gout in the older adult involves careful selection of treatment based on potential benefits and consequences of therapy, considered in tandem with individual patient-specific characteristics. ClinicalTrials.gov identifiers NCT00549549, NCT01101035, NCT00241839, NCT01157936, NCT00997542, NCT00288158, and NCT00987415.
Urinary tract infections in the elderly population.
Matthews SJ, Lancaster JW
Am J Geriatr Pharmacother · 2011 Oct · PMID 21840265 · Publisher ↗
BACKGROUND: Urinary tract infections (UTIs) are a common problem in the elderly population. The spectrum of disease varies from a relatively benign cystitis to potentially life-threatening pyelonephritis. OBJECTIVE: This...
BACKGROUND: Urinary tract infections (UTIs) are a common problem in the elderly population. The spectrum of disease varies from a relatively benign cystitis to potentially life-threatening pyelonephritis. OBJECTIVE: This review covers the management of asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, antibiotic resistance, catheter-associated bacteriuria/symptomatic UTIs, and antibiotic prophylaxis for recurrent infections in elderly men and women. METHODS: Literature was obtained from English-language searches of MEDLINE (1966-April 2011), Cochrane Library, BIOSIS (1993-April 2011), and EMBASE (1970-April 2011). Further publications were identified from citations of resulting articles. Search terms included, but were not limited to, urinary tract infections, asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, antibiotic resistance, catheter associated urinary tract infections, recurrent urinary tract infections, and elderly. RESULTS: The prevalence of UTIs in elderly women depends on the location in which these women are living. For elderly women living in the community, UTIs compromise the second most common infection, whereas in residents of long-term care facilities (LTCFs) and hospitalized subjects, it is the number one cause of infection. The spectrum of patient presentation varies from classic signs and symptoms in the independent elderly population to atypical presentations, including increased lethargy, delirium, blunted fever response, and anorexia. Although there are few guidelines specifically directed toward the management of UTIs in the elderly population, therapy generally mirrors the recommendations for the younger adult age groups. When choosing a treatment regimen, special attention must be given to the severity of illness, living conditions, existing comorbidities, presence of external devices, local antibiotic resistance patterns, and the ability of the patient to comply with therapy. CONCLUSIONS: Improved guidelines for the diagnosis and management of UTIs in the elderly population are needed. Better techniques to evaluate and prevent catheter-associated bacteriuria and UTIs await improved diagnostic modalities and catheter technologies. Alternative methods for prophylaxis of patients who suffer from recurrent infections must be found while minimizing the risk of developing or propagating antibiotic resistance.
Dawn of a new era for the American journal of geriatric pharmacotherapy.
Hanlon JT, Schmader KE
Am J Geriatr Pharmacother · 2011 Aug · PMID 21821206 · Publisher ↗
Abstract loading — click title to view on PubMed.
Cytochrome P450 2D6 phenotyping in an elderly population with dementia and response to galantamine in dementia: a pilot study.
Clarke JA, Cutler M, Gong I … +3 more , Schwarz UI, Freeman D, Dasgupta M
Am J Geriatr Pharmacother · 2011 Aug · PMID 21803659 · Publisher ↗
BACKGROUND: The cytochrome P450 (CYP) 2D6 enzyme is involved in the metabolism of many drugs used by the elderly population. Variations in its activity can lead to altered drug response. However, few studies on the activ...
BACKGROUND: The cytochrome P450 (CYP) 2D6 enzyme is involved in the metabolism of many drugs used by the elderly population. Variations in its activity can lead to altered drug response. However, few studies on the activity of this enzyme system have enrolled the elderly population. OBJECTIVE: The goal of this pilot study was to assess the feasibility of in vivo phenotyping of CYP2D6 in an elderly population with dementia and to determine if part of the variability in response to treatment with galantamine is attributable to CYP2D6 phenotype. METHODS: Patients with dementia attending geriatric clinics and receiving galantamine treatment for at least 6 months were enrolled in this case-control study. CYP2D6 phenotype was determined by analysis of the urinary concentrations of the probe drug dextromethorphan and its primary metabolite dextrorphan after ingestion of 30 mg of dextromethorphan. Patients were classified as robust responders to galantamine if their cognitive testing, as measured by using scores on the Mini-Mental State Examination or Alzheimer's Disease Assessment Scale-Cognitive subscale, had not changed or had improved after 6 months of treatment. RESULTS: Forty-three patients (23 men, 20 women; mean age, 78.4 years; 98% white) underwent phenotyping. The mean number of concomitantly prescribed medications was 5.7, and 16 patients (37%) were receiving other CYP2D6 substrate or inhibitor drugs. The distribution of CYP2D6 phenotype was similar to that seen in other white populations. There was no correlation between the phenotypic metabolic ratio and age, the number of routinely taken medications, whether patients were receiving other prescribed substrate or inhibitor drugs of CYP2D6 (P = 0.63), or whether they were a robust responder (P = 0.47). CONCLUSIONS: Urinary assays of CYP2D6 phenotype are technically feasible in older individuals with dementia who are taking multiple medications, and may be a useful clinical tool in this population. However, the study was unable to make inferences about an association between CYP2D6 phenotype and galantamine responsiveness.
Medication discrepancies identified at time of hospital discharge in a geriatric population.
Stitt DM, Elliott DP, Thompson SN
Am J Geriatr Pharmacother · 2011 Aug · PMID 21763215 · Publisher ↗
BACKGROUND: It has been reported that 14.1% of geriatric patients experience ≥1 medication discrepancies after hospitalization. OBJECTIVE: The goal of this study was to identify and characterize discharge medication list...
BACKGROUND: It has been reported that 14.1% of geriatric patients experience ≥1 medication discrepancies after hospitalization. OBJECTIVE: The goal of this study was to identify and characterize discharge medication list discrepancies among geriatric patients and to describe characteristics associated with discrepancies. METHODS: An institutional review board-approved retrospective review was conducted of patients aged ≥65 years discharged from hospitalist and internal medicine services at a large tertiary care hospital from August 2008 to December 2009. A random cohort of 200 patients was selected and categorized by age, gender, attending medical service, and the absence or presence of a pharmacist on the service. Medication lists were obtained from physician discharge summaries, discharge orders, and nursing discharge lists. RESULTS: A total of 1923 medication discrepancies were identified, consisting of 402 related to the absence or presence of a medication, 298 related to the dosage administered at one time, 223 related to the number of daily doses, and 1000 related to the route of administration. Physician discharge summaries contained the most medication discrepancies. There was no relationship between patient age and the number of medication discrepancies (r(2) = 0.006; P = 0.279), whereas there was a linear relationship between the number of medications and the number of discrepancies (r(2) = 0.249; P < 0.001). The internal medicine team with a pharmacist had a lower average number of discrepancies per patient compared with other medicine services that did not have a pharmacist present. CONCLUSIONS: Medication discrepancies at the time of hospital discharge are a common occurrence for geriatric patients. Physician summaries might be the least reliable source of discharge medication lists. The number of discrepancies appears to not be associated with patient age, but rather with the number of medications at discharge. Discrepancies among medication lists are common, and the presence of a pharmacist may reduce the number that occur.
Cholinesterase inhibitors: applying pharmacokinetics to clinical decision making.
Gomolin IH, Smith C, Jeitner TM
Am J Geriatr Pharmacother · 2011 Aug · PMID 21763214 · Publisher ↗
BACKGROUND: Cholinesterase inhibitors are indicated for the treatment of Alzheimer-type dementia. There are few direct comparative studies of adverse effects or studies to suggest clinical superiority of one inhibitor ov...
BACKGROUND: Cholinesterase inhibitors are indicated for the treatment of Alzheimer-type dementia. There are few direct comparative studies of adverse effects or studies to suggest clinical superiority of one inhibitor over the others. OBJECTIVE: The objective of this study was to relate pharmacokinetic differences among the agents to potential clinical considerations. METHODS: Population pharmacokinetics were obtained from US Food and Drug Administration-approved label information and published literature. Plasma concentration-time profiles were derived from these parameters using noncompartmental pharmacokinetic modeling. RESULTS: Plasma concentration profiles differed significantly among different agents and between different formulations of the same agent. CONCLUSIONS: The initial choice among the various cholinesterase inhibitors requires consideration to adherence and cost. Consideration to differences in pharmacokinetics among these drugs provides a better understanding for the clinical practice of dose titration, identification and management of drug-related side effects, and lapses in therapy. Pharmacokinetic considerations among the various agents and formulations provide the clinician with options to enhance therapy when these agents are chosen for treatment of patients with Alzheimer-type dementia.
Racial disparities in quality of medication use in older adults: findings from a longitudinal study.
Roth MT, Esserman DA, Ivey JL … +1 more , Weinberger M
Am J Geriatr Pharmacother · 2011 Aug · PMID 21664193 · Full text
BACKGROUND: The quality of medication use in older adults is suboptimal, with a large percentage of individuals not receiving recommended care. Most efforts to evaluate the quality of medication use target high-risk drug...
BACKGROUND: The quality of medication use in older adults is suboptimal, with a large percentage of individuals not receiving recommended care. Most efforts to evaluate the quality of medication use target high-risk drugs, appropriate treatment of prevalent chronic disease states, or a set of predefined quality indicators of medication use rather than the patient. It is also suggested that racial differences in the quality of medication use may exist in older adults. OBJECTIVE: This study was conducted to determine the prevalence, number, and types of medication-related problems in older adults, examining the impact of race on quality medication use. METHODS: This was a prospective cohort study involving in-home interviews and medical record reviews of community-residing older adults, stratified by race, conducted 3 times over 1 year. No intervention to address medication-related problems was performed. The quality of medication use was reported as medication-related problems by clinical pharmacists. RESULTS: Of the 200 participants (100 blacks, 100 whites), mean age was 78.3 (whites) and 75.5 (blacks), and the majority of patients were female. Although whites used more medications than blacks (mean, 11.6 vs 9.7; P < 0.01), blacks had more medication-related problems per person than whites (mean, 6.3 vs 4.9; P < 0.01). All patients had at least 1 medication-related problem. Common problems at baseline, 6 months, and 12 months for both whites and blacks were undertreatment, suboptimal drug use, suboptimal dosing, nonadherence, and less costly alternative available. Blacks had significantly higher rates of nonadherence than whites (68% vs 42%; P < 0.01). Over the 12-month study, the number of medication-related problems not only persisted but increased (adjusted P = 0.0168). CONCLUSIONS: Medication-related problems were prevalent in both black and white older adults and persisted over 1 year. Blacks had more medication-related problems than whites, including higher rates of nonadherence. These findings require further study to better understand racial disparities in the quality of medication use in older adults and the impact of race on specific medication-related problems.
Prevalence of diabetes and the burden of comorbid conditions among elderly nursing home residents.
Dybicz SB, Thompson S, Molotsky S … +1 more , Stuart B
Am J Geriatr Pharmacother · 2011 Aug · PMID 21659006 · Publisher ↗
BACKGROUND: Although the reported prevalence of diabetes in nursing home residents varies greatly among studies, there remains a common trend: increasing prevalence. Diabetes in the elderly is often associated with the p...
BACKGROUND: Although the reported prevalence of diabetes in nursing home residents varies greatly among studies, there remains a common trend: increasing prevalence. Diabetes in the elderly is often associated with the presence of multiple comorbid conditions. However, limited data exist regarding the characteristics, symptom severity, disease management, and outcomes of care for residents of nursing homes with diabetes. OBJECTIVE: Our aim was to estimate the prevalence of diabetes in a national sample of skilled nursing facility (SNF) residents over a 12-month period and to examine differences in the burden of comorbidities between elderly residents with and without diabetes, including prevalence and severity of comorbidities, pharmacotherapy associated with these conditions, and cost. METHODS: This was a multicenter, observational, medical utilization evaluation study in 23 geographically representative SNFs in the United States. Comorbidities, cognition, physical activity, utilization of health services, and medications were obtained from medical chart audits, minimum data set records, and prescription claims files. Chart abstraction was performed between June 2006 and March 2007. Residents eligible for inclusion in the prevalence analysis were aged ≥65 years, did not receive hospice care, and were not in a persistent vegetative condition. RESULTS: A total of 2317 residents met the inclusion criteria and were included in the prevalence analysis; 761 (32.8%) had diabetes. Residents with a full minimum data set assessment within 12 months before chart abstraction (n = 2095) were included in the comorbid burden analysis. Compared with those without diabetes, a greater proportion of residents with diabetes were younger, male, Hispanic or African American, and were overweight or obese. Residents with diabetes had a greater comorbidity burden (Hierarchical Condition Category, 1.90 vs 1.58), including more prescribed medications for certain common comorbid conditions (including angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers [46% vs 24%], diuretics [44% vs 34%], statins [40% vs 18%], or antiplatelets/antithrombotics [43% vs 37%]), and experienced more hospitalizations (37% vs 18% at 6 months) than residents without diabetes. CONCLUSION: Nearly one third of elderly SNF residents had diabetes. These patients, compared with SNF residents without diabetes, had a greater comorbid burden, were prescribed more medications to treat these conditions, and had more hospitalizations.
Methodological issues in pharmacotherapy research in older adults.
Orwig D, Rickles NM, Martin LG
Am J Geriatr Pharmacother · 2011 Jun · PMID 21636042 · Publisher ↗
BACKGROUND: The shifting of demographics to an aging society with multiple chronic illnesses and increased heterogeneity has created an undeniable imperative regarding the knowledge about pharmacotherapy in older patient...
BACKGROUND: The shifting of demographics to an aging society with multiple chronic illnesses and increased heterogeneity has created an undeniable imperative regarding the knowledge about pharmacotherapy in older patients, especially because older adults have a higher rate of medication use compared with the general population. More research on pharmacotherapy in older adults is needed to maximize not only the appropriate use of medications but also the benefits of available treatments in this historically underrepresented group. Investigators face many challenges that may greatly affect the outcomes of research on pharmacotherapy in older adults. OBJECTIVE: This commentary discusses the common challenges of research on pharmacotherapy in older adults and provides strategies to overcome such challenges. METHODS: The following databases were searched for examples of concepts (dates: 1976-September 14, 2010; key terms: research [in the title], aged, elderly, older adult, and geriatric): PubMed, Cumulative Index to Nursing and Allied Health Literature Database (CINAHL), Family & Societal Studies Worldwide, Women's Studies International, Academic Search Premier, Health Source: Academic/Nursing Edition, ISI Web of Knowledge, International Pharmaceutical Abstracts, PsycInfo, and Social Work Abstracts. RESULTS: There are several methodological challenges related to study design, including the measurement of outcomes and the analytical plan; study implementation, such as the recruitment of sites and individuals; the informed-consent process; retention; and other practical considerations. A crucial area to consider is the measurement of medication adherence, both as an independent factor and as a confounder. Many challenges of research in older patients reflect the complexities of the aging process, including psychosocial consequences, and the resultant effects on study participation and outcomes. CONCLUSION: It is hoped that the recommendations provided will help researchers and clinicians overcome the methodological challenges of conducting research on pharmacotherapy in older adults, thereby fostering more studies that critically evaluate pharmacotherapy and medication-management services and maximizing treatment outcomes in older adults.
Out-of-pocket drug costs and drug utilization patterns of postmenopausal Medicare beneficiaries with osteoporosis.
Conwell LJ, Esposito D, Garavaglia S … +6 more , Meadows ES, Colby M, Herrera V, Goldfarb S, Ball D, Marciniak M
Am J Geriatr Pharmacother · 2011 Aug · PMID 21616722 · Publisher ↗
BACKGROUND: The Medicare Part D coverage gap has been associated with lower adherence and drug utilization and higher discontinuation. Because osteoporosis has a relatively high prevalence among Medicare-eligible postmen...
BACKGROUND: The Medicare Part D coverage gap has been associated with lower adherence and drug utilization and higher discontinuation. Because osteoporosis has a relatively high prevalence among Medicare-eligible postmenopausal women, we examined changes in utilization of osteoporosis medications during this coverage gap. OBJECTIVES: The purpose of this study was to investigate changes in out-of-pocket (OOP) drug costs and utilization associated with the Medicare Part D coverage gap among postmenopausal beneficiaries with osteoporosis. METHODS: This retrospective analysis of 2007 pharmacy claims focuses on postmenopausal female Medicare beneficiaries enrolled in full-, partial-, or no-gap exposure standard or Medicare Advantage prescription drug plans (PDPs), retiree drug subsidy (RDS) plans, or the low-income subsidy program. We compared beneficiaries with osteoporosis who were taking teriparatide (Eli Lilly and Company, Indianapolis, Indiana) (n = 5657) with matched samples of beneficiaries who were taking nonteriparatide osteoporosis medications (NTO; n = 16,971) or who had other chronic conditions (OCC; n = 16,971). We measured average monthly prescription drug fills and OOP costs, medication discontinuation, and skipping. RESULTS: More than half the sample reached the coverage gap; OOP costs then rose for teriparatide users enrolled in partial- or full-gap exposure plans (increase of 121% and 186%; $300 and $349) but fell for those in no-gap exposure PDPs or RDS plans (decrease of 49% and 30%; $131 and $40). OOP costs for beneficiaries in partial- or full-gap exposure PDPs increased >120% (increase of $144 and $176) in the NTO group and nearly doubled for the OCC group (increase of $124 and $151); these OOP costs were substantially lower than those for teriparatide users. Both teriparatide users and NTO group members discontinued or skipped medications more often than persons in the OCC group, regardless of plan or benefit design. CONCLUSION: Medication discontinuation and OOP costs among beneficiaries with osteoporosis were highest for those enrolled in Part D plans with a coverage gap. Providers should be aware of potential cost-related nonadherence among Medicare beneficiaries taking osteoporosis medications.
Anorgasmia with gabapentin may be common in older patients.
Perloff MD, Thaler DE, Otis JA
Am J Geriatr Pharmacother · 2011 Jun · PMID 21602106 · Publisher ↗
BACKGROUND: Gabapentin is commonly used to treat neuropathic pain, seizures, and bipolar disease in older and elderly patients. It is preferred for its well-tolerated side effect profile. Anorgasmia with gabapentin use i...
BACKGROUND: Gabapentin is commonly used to treat neuropathic pain, seizures, and bipolar disease in older and elderly patients. It is preferred for its well-tolerated side effect profile. Anorgasmia with gabapentin use is reported, with most cases in young patients. CASE SUMMARY: This report describes 4 older patients who experienced anorgasmia while taking gabapentin. Of 15 patients initiated on gabapentin in 18 months, 3 male patients aged 73, 76, and 78 years experienced dose-dependent anorgasmia. A fourth case, a 59-year-old female patient, was noted in another clinic. Orgasm returned when gabapentin was reduced or stopped. Although this is not a blinded study, anorgasmia in 3 of 15 patients newly initiated on gabapentin (3 of 11 in those aged >50 years) seems to represent a much higher incidence than the originally reported <1% in epilepsy clinical trials. Outside of erectile dysfunction, clinicians rarely ask older patients about sexual function. CONCLUSION: Gabapentin-associated anorgasmia may be more common in older patients and appears to be dose dependent.
Antipsychotic use and the risk of diabetes in nursing home residents with dementia.
Jalbert JJ, Daiello LA, Eaton CB … +2 more , Miller SC, Lapane KL
Am J Geriatr Pharmacother · 2011 Jun · PMID 21596626 · Publisher ↗
BACKGROUND: Growing evidence suggests an association between antipsychotic use and diabetes onset in schizophrenia, but little is known about this association among patients with dementia. OBJECTIVE: The aim of this stud...
BACKGROUND: Growing evidence suggests an association between antipsychotic use and diabetes onset in schizophrenia, but little is known about this association among patients with dementia. OBJECTIVE: The aim of this study was to quantify the association between antipsychotic use and the risk of diabetes onset among nursing home residents with dementia. METHODS: We conducted a nested case-control study in 29,203 long-stay Medicaid-eligible residents living in nursing homes in California, Florida, Illinois, New York, and Ohio between January 2001 and December 2002 who were at least 65 years old with a dementia diagnosis and no record of diabetes within 90 days of nursing home admission. We identified 762 incident cases of diabetes and randomly selected up to 5 controls, matched on nursing home and quarter of minimum data set (MDS) assessment (N = 2646). Cases of incident diabetes were identified from MDS assessments and Medicaid claims, medication use was ascertained from Medicaid pharmacy files, and resident characteristics were obtained from MDS assessments. RESULTS: Relative to non-users of antipsychotics, use of atypical antipsychotics was not associated with diabetes onset (adjusted odds ratio [AOR] = 1.03; 95% CI, 0.84-1.27) and risk of diabetes did not increase with length of time on treatment. Conventional antipsychotic treatment was associated with diabetes onset, particularly when treatment duration was <30 days (AOR = 2.70; 95% CI, 1.57-4.65). CONCLUSIONS: Among nursing home residents with dementia, conventional antipsychotic therapy, particularly short-term therapy, increased their risk of developing diabetes. Atypical antipsychotic use was not associated with an increased risk of diabetes onset.
Secondary prevention of stroke in the elderly: a review of the evidence.
Alhusban A, Fagan SC
Am J Geriatr Pharmacother · 2011 Jun · PMID 21570361 · Publisher ↗
BACKGROUND: Stroke is a major health problem with significant impact on the affected individuals and the whole community. In light of stroke being the leading cause of disability, the ageing of the population and the hig...
BACKGROUND: Stroke is a major health problem with significant impact on the affected individuals and the whole community. In light of stroke being the leading cause of disability, the ageing of the population and the high incidence of stroke among the elderly, highlight the importance of primary and secondary prevention interventions among this group. The elderly generally have been underrepresented in clinical trials, creating many uncertainties and less optimal medical care for this group of patients. OBJECTIVE: This review aims to make evidence-based management recommendations for secondary stroke prevention in the elderly. METHODS: Secondary prevention-related primary literature was identified using MEDLINE and PubMed (1982 to present) with combinations of the following search terms being employed: antiplatelets, aspirin, atrial fibrillation, elderly, geriatrics, hypertension, lipids, secondary prevention, statins, stroke, and warfarin. In addition, the references of these articles were also reviewed. RESULTS: Twenty-three clinical trials were included in this review, covering different aspects of secondary stroke prevention. Many of these trials were not specifically limited to the elderly, but conclusions related to their care can be derived from them. Although the American Heart Association/American Stroke Association guidelines suggest an equal benefit of aspirin, aspirin/dipyridamole, and clopidogrel in secondary prevention, the use of aspirin in the elderly may be preferred for reasons related to compliance and experience. Warfarin was largely avoided in the management of elderly stroke patients in the past, although available evidence demonstrates its efficacy and safety as a first choice for elderly patients with atrial fibrillation and presumed cardiac source of emboli. Lowering blood pressure among the elderly is an important aspect of secondary stroke prevention and can be achieved with the same agents used among younger age groups with a preference for a thiazide diuretic/angiotensin-converting enzyme inhibitor combination that has proven efficacy among elderly patients. Available evidence supports the use of statins among elderly patients with history of stroke or transient ischemic attack (TIA), and the derived benefit of treatment does not differ significantly from that in the younger age group. Elderly patients with 50% to 99% carotid artery stenosis and history of stroke or TIA should be considered for early carotid endarterectomy to reduce recurrent stroke. CONCLUSION: Age should not be considered a barrier for the provision of optimal secondary prevention interventions. The available evidence supports similar and sometimes superior derived benefit from secondary preventive stroke measures in the elderly compared with that seen in younger patients.
Risk of serious cardiac events in older adults using antipsychotic agents.
Mehta S, Chen H, Johnson M … +1 more , Aparasu RR
Am J Geriatr Pharmacother · 2011 Apr · PMID 21565711 · Publisher ↗
BACKGROUND: Antipsychotic agents can lead to severe cardiovascular adverse events due to multiple mechanisms involving electrophysiologic and metabolic effects. Few epidemiologic studies have evaluated the risk of seriou...
BACKGROUND: Antipsychotic agents can lead to severe cardiovascular adverse events due to multiple mechanisms involving electrophysiologic and metabolic effects. Few epidemiologic studies have evaluated the risk of serious cardiovascular-related events in typical and atypical antipsychotic users. OBJECTIVE: The purpose of this study was to compare the risk of serious cardiac events in older adults taking typical antipsychotics with those taking atypical antipsychotics. METHODS: Prescription and medical information were derived from the IMS LifeLink Health Plan Claims database. The study involved a retrospective cohort of older adults (≥50 years) taking atypical or typical antipsychotics from July 1, 2000, to December 31, 2007. The primary outcome measure was hospitalization or emergency room visit due to serious cardiac events, including thromboembolism, myocardial infarction, cardiac arrest, and ventricular arrhythmias within 1 year after the index date. The 2 groups were matched on a propensity score to minimize the baseline differences between the groups. Survival analysis was conducted on the matched cohort to assess the risk of serious cardiovascular events in typical versus atypical users. RESULTS: A total of 5580 patients were selected in each antipsychotic users group after propensity score matching. Serious cardiac events were found in 666 (11.9 %) atypical antipsychotic users and 698 (12.4%) typical antipsychotic users. Survival analysis revealed that typical antipsychotic users were at increased risk of serious cardiovascular events compared with atypical antipsychotic users (hazard ratio = 1.21; 95% CI, 1.04-1.40) after controlling for other factors. CONCLUSIONS: Moderate increases in risk of serious cardiac events are associated with older adults using typical antipsychotic agents compared with atypical users. Health care professionals should carefully evaluate the benefit/risk ratio of antipsychotic agents before prescribing these agents to a vulnerable population.
Prevalence and predictors of antidepressant prescribing in nursing home residents in the United States.
Karkare SU, Bhattacharjee S, Kamble P … +1 more , Aparasu R
Am J Geriatr Pharmacother · 2011 Apr · PMID 21565710 · Publisher ↗
BACKGROUND: Late-life depression is a common psychiatric disorder associated with increased morbidity and mortality. Depression is often under-detected and undertreated in elderly nursing home residents. OBJECTIVES: The...
BACKGROUND: Late-life depression is a common psychiatric disorder associated with increased morbidity and mortality. Depression is often under-detected and undertreated in elderly nursing home residents. OBJECTIVES: The aim of this study was to examine the prevalence of antidepressant drug use and to identify the factors associated with its use among elderly nursing home residents. METHODS: The study involved the analysis of a nationally representative sample of prescription and resident files from the 2004 National Nursing Home Survey (NNHS). The study sample included all elderly nursing home residents ≥65 years of age. The analysis focused on prescribing from any antidepressant class, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin modulators, serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and others. Descriptive weighted analysis was performed to examine antidepressant use prevalence patterns in elderly nursing home residents. Multiple logistic regression analysis within the conceptual framework of Anderson's behavioral model was used to examine the predisposing, enabling, and need characteristics associated with antidepressant use. RESULTS: According to the 2004 NNHS, overall prevalence of antidepressant use among elderly nursing home residents was 46.22% (95% CI, 45.16-47.27). Most antidepressant users were ≥85 years of age (49.7%), female (75.7%), non-Hispanic (96.4%), and white (91.1%). The most prescribed class of antidepressants was SSRIs (31.09%; 95% CI, 30.12-32.07), followed by serotonin modulators (4.65%; 95% CI, 4.22-5.09), SNRIs (2.78%; 95% CI, 2.45-3.12), TCAs (2.34%; 95% CI, 2.03-2.65), and MAOIs (0.01%; 95% CI, 0.00-0.03). Citalopram (12.92%; 95% CI, 12.21-13.63) was the most prescribed individual antidepressant, followed by mirtazapine (10.19%; 95% CI, 9.55-10.84). Among the predisposing characteristics, age, race, and marital status were significantly associated with antidepressant use. The odds of receiving an antidepressant were lower for those aged ≥85 years and those who were unmarried elderly residents, when compared with their counterparts; whites were more likely to receive an antidepressant than nonwhites. Enabling factors such as Medicaid and bed capacity significantly predicted antidepressant use. Having Medicaid was positively associated with antidepressant prescription, whereas an increase in the total number of beds decreased the probability of an antidepressant prescription. Among need characteristics, the likelihood of antidepressant prescription use decreased with increased dependence in decision-making ability and out-of-bed mobility. The presence of depressed mood indicators and a history of falls/fractures increased the likelihood of antidepressant prescription use. The odds of receiving an antidepressant increased with diagnosis of depression but decreased with diagnosis of anxiety. CONCLUSION: Nearly half of elderly nursing home residents received antidepressants. In addition to need factors, predisposing and enabling factors played an important role in influencing the use of antidepressants in elderly nursing home residents.
Use of orexigenic medications in geriatric patients.
Thomas DR
Am J Geriatr Pharmacother · 2011 Apr · PMID 21565709 · Publisher ↗
BACKGROUND: The loss of appetite, anorexia, is commonly observed in older persons and associated with adverse outcomes. It is becoming increasingly apparent that anorexia is the chief factor in producing weight loss in o...
BACKGROUND: The loss of appetite, anorexia, is commonly observed in older persons and associated with adverse outcomes. It is becoming increasingly apparent that anorexia is the chief factor in producing weight loss in older adults. Although common and expected in acute illness, anorexia is also frequently associated with chronic diseases and leads to inadequate nutrient intake. OBJECTIVE: The aim of this paper was to review clinical studies on the use of orexigenic drugs to stimulate appetite. METHODS: Clinical trials were identified related to improving appetite and/or weight gain in older persons. Articles were identified by Ovid search using terms nutrition, anorexia, cachexia, weight loss, orexigenic drugs, and by searching references from retrieved papers. RESULTS: Environmental and nutritional interventions to improve intake should be the first intervention. When these fail to produce adequate intake, orexigenic drugs should be considered. No drug has received approval from the US Food and Drug Administration for geriatric anorexia. CONCLUSIONS: In the presence of adequate food, weight loss most often is due to cytokine-associated cachexia and anorexia. Assessment of changes in appetite is essential to evaluating older persons with weight loss. When anorexia is identified, a search for reversible causes should be instituted. Intervention should first be aimed at the provision of adequate calories and protein, often in the form of high-density nutritional supplements. Failure to respond to adequate nutrition or supplements should trigger a concern for cachexia. Orexigenic drugs have been reported to improve appetite and produce weight gain. The mechanism is unknown, but it may relate to suppression of proinflammatory cytokines.
Psychotropic drug use in late life: a diverse look at an expanding field.
Blazer D
Am J Geriatr Pharmacother · 2011 Apr · PMID 21565708 · Publisher ↗
Abstract loading — click title to view on PubMed.
Improvement in drug-induced parkinsonism with electroconvulsive therapy.
Baez MA, Avery J
Am J Geriatr Pharmacother · 2011 Jun · PMID 21565562 · Publisher ↗
BACKGROUND: Drug-induced parkinsonism is a common medication side effect. OBJECTIVE: The present report describes the case of a depressed elderly woman who developed parkinsonism after receiving risperidone and who had i...
BACKGROUND: Drug-induced parkinsonism is a common medication side effect. OBJECTIVE: The present report describes the case of a depressed elderly woman who developed parkinsonism after receiving risperidone and who had improvement of her depression and parkinsonism after electroconvulsive therapy (ECT). CASE SUMMARY: A 67-year-old white female was admitted to a psychiatry ward for a major depressive episode with psychotic features. The patient developed pronounced parkinsonian features after taking risperidone, which did not improve with discontinuation of the drug, or with benztropine and carbidopa/levodopa. A total score of 6 was achieved using Naranjo's adverse drug reaction causality algorithm, suggesting risperidone was a probable cause of this adverse event. The patient's depression and parkinsonian symptoms did not improve until after initiation of ECT. After 19 treatments, the patient had resolution of her depression and only mild bradykinesia remained. CONCLUSIONS: This was a case of probable drug-induced parkinsonism in an elderly woman who had improvement of her depression and parkinsonism after receiving ECT.
Primary care providers' perspectives on psychoactive medication disorders in older adults.
Payne M, Gething M, Moore AA … +1 more , Reid MC
Am J Geriatr Pharmacother · 2011 Jun · PMID 21550858 · Full text
BACKGROUND: Compared with younger adults, older adults consume a disproportionate percentage of pain and sleep medications. Some studies have reported that psychoactive medication misuse and abuse in older populations is...
BACKGROUND: Compared with younger adults, older adults consume a disproportionate percentage of pain and sleep medications. Some studies have reported that psychoactive medication misuse and abuse in older populations is a significant problem. OBJECTIVES: The aim of this study was to understand the perspective of primary care providers (PCPs) regarding the extent and clinical presentations of misuse and abuse of psychoactive medications in older patients and to explore PCPs' perceived barriers to identifying affected individuals. METHODS: Seventeen physicians and 5 nurse practitioners from 2 ambulatory care practices serving older adults in New York City participated in this study. Six focus group discussions were audiotaped and transcribed. Two raters coded transcripts to identify recurring themes. Qualitative analysis software was employed for data coding and sorting purposes. RESULTS: Although PCPs indicated that only a small percentage of older patients were actively misusing or abusing their psychoactive medications (average estimate given by providers, 8%), they felt that these patients placed significant time burdens on them. Perceived risk factors included psychiatric disorders, previous substance abuse history, and cognitive impairment, but many PCPs found it impossible to predict which patients were at increased risk. PCPs identified multiple barriers to identifying affected patients, including lack of communication (between provider and patient, provider and patients' caregivers, and between different providers), nonspecific symptoms, and the lack of a clear definition of misuse and abuse. CONCLUSIONS: The lack of a clear definition, absence of well-defined risk factors, and ambiguous clinical manifestations of psychoactive medication misuse and abuse present substantial barriers to diagnosis. A standard, age-appropriate definition could help PCPs establish a diagnosis, clarify what constitutes appropriate psychoactive medication use, define the extent of the problem, and pave the way for the development of effective screening and diagnostic tools.
Balance control improves following replacement of paroxetine with venlafaxine and levodopa in a case of microvascular dementia.
McDonald J, Corbeil P, Pourcher E
Am J Geriatr Pharmacother · 2011 Apr · PMID 21507731 · Publisher ↗
BACKGROUND: Postural instability is a concern in several neurologic conditions and also among the elderly. Dysfunction in serotonergic, noradrenergic, and dopaminergic pathways may be involved in the etiology of postural...
BACKGROUND: Postural instability is a concern in several neurologic conditions and also among the elderly. Dysfunction in serotonergic, noradrenergic, and dopaminergic pathways may be involved in the etiology of postural imbalance. OBJECTIVE: The objective of this case report was to quantify, using computerized posturography, substitution with venlafaxine, and later levodopa, in a suspected case of postural instability with paroxetine. CASE SUMMARY: Presented is an 86-year-old woman with frequent falls and a Parkinson-like syndrome of the lower limbs secondary to microvascular dementia. Paroxetine was gradually discontinued and exchanged for venlafaxine, 37.5 mg twice daily. Before and after medication changes, static posturography was performed under eyes open and closed conditions. Following 3 months of venlafaxine, the patient showed significant improvement from baseline, however, venlafaxine was then reduced to 37.5 mg at bedtime. Six months later, levodopa was introduced and further improvement was observed. It is possible that venlafaxine, which maintains a more balanced affinity for serotonin and norepinephrine transporters, may have provided postural benefit. Decreased sedation secondary to venlafaxine reduction may have elicited further improvements in addition to the increased lower limb functionality observed with levodopa. CONCLUSIONS: For patients on antidepressants, switching medications may be worthwhile in those with balance problems. The prudent addition of medications may also be an option.
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