The American Journal Of Geriatric Pharmacotherapy[JOURNAL]
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200 papers
Bisphosphonate-related subtrochanteric femoral fractures.
Gunawardena I, Baxter M, Rasekh Y
Am J Geriatr Pharmacother · 2011 Jun · PMID 21470918 · Publisher ↗
BACKGROUND: Hip fractures are important because they are associated with an increased rate of death, substantial morbidity, enormous costs, and devastating effects on independence and quality of life. Bisphosphonates hav...
BACKGROUND: Hip fractures are important because they are associated with an increased rate of death, substantial morbidity, enormous costs, and devastating effects on independence and quality of life. Bisphosphonates have proven efficacy in reducing the incidence of spine and nonspine fractures. Several case series and multiple individual case reports from around the world suggest that some subtrochanteric fractures and those of the femoral shaft might occur in patients who have been treated with long-term bisphosphonate therapy. CASE SUMMARY: We present a case in the United Kingdom, where a patient presented with bilateral, sequential bisphosphonate-related subtrochanteric fractures. Several unique clinical and radiographic features surrounding these atypical fractures that have been identified in the literature are illustrated in this case. CONCLUSIONS: There is no rationale for withholding bisphosphonate therapy from patients with osteoporosis, although continued use of bisphosphonates beyond a treatment period of 3 to 5 years should be reevaluated annually. In patients who have been on long-term bisphosphonate therapy, physicians should specifically solicit information of unique clinical features and consider imaging, when appropriate.
The review article by Wood et al on nonmotor symptoms of Parkinson’s disease (PD) in the August 2010 edition of The American Journal of Geriatric Pharmacotherapy.
Wagg A
Am J Geriatr Pharmacother · 2011 Feb · PMID 21459313 · Publisher ↗
Abstract loading — click title to view on PubMed.
Linezolid-associated hypoglycemia in a 64-year-old man with type 2 diabetes.
Bodnar T, Starr K, Halter JB
Am J Geriatr Pharmacother · 2011 Feb · PMID 21459312 · Publisher ↗
BACKGROUND: Older diabetic patients are at increased risk for skin infections, often with methicillin-resistant Staphylococcus aureus (MRSA). Linezolid offers oral therapy with MRSA coverage. We present a case of linezol...
BACKGROUND: Older diabetic patients are at increased risk for skin infections, often with methicillin-resistant Staphylococcus aureus (MRSA). Linezolid offers oral therapy with MRSA coverage. We present a case of linezolid-associated hypoglycemia in a 64-year-old diabetic patient with presumed MRSA cellulitis. CASE SUMMARY: A 64-year-old man with diabetes was treated for cellulitis. Linezolid was started when amoxicillin/clavulanate failed. Within 7 days, he developed frequent diaphoresis and tremulousness, with glucoses of 30 to 60 mg/dL. Hypoglycemia worsened despite decreasing insulin use, discontinuing glyburide, and increasing caloric intake. The day of admission, he awoke with a glucose level of 30 mg/dL. He took no medications, ate a large breakfast, and presented to clinic. He was symptomatic with a glucose level of 35 mg/dL. Hypoglycemia persisted despite IV dextrose. Linezolid was discontinued immediately in favor of vancomycin. Dextrose was weaned and his diabetes medications were resumed without further hypoglycemia. CONCLUSIONS: Linezolid has monoamine oxidase (MAO) inhibitory properties, and MAO inhibitors have been reported to contribute to hypoglycemia. The use of linezolid in older diabetic patients, especially those patients already taking agents with the potential to cause hypoglycemia, represents an area of concern. Increased comorbidities and polypharmacy in geriatric patients adds to this concern.
Potentially procholinergic effects of medications commonly used in older adults.
Rockwood K, Walsh R, Martin E … +1 more , Darvesh S
Am J Geriatr Pharmacother · 2011 Feb · PMID 21459311 · Publisher ↗
BACKGROUND: Older adults are susceptible to a variety of illnesses, many of which can be treated with medications that may need to be used for the long term. Considerable attention has been paid to drugs that, in additio...
BACKGROUND: Older adults are susceptible to a variety of illnesses, many of which can be treated with medications that may need to be used for the long term. Considerable attention has been paid to drugs that, in addition to their intended function, may have an anticholinergic effect that results in undesirable side effects, including impairment in cognition. Cholinesterase inhibitors are used as procholinergic drugs to improve cognitive dysfunction in Alzheimer's disease. We hypothesized that some of the drugs commonly used by older adults might, in addition to their intended function, also have procholinergic effects by virtue of inhibiting cholinesterases. OBJECTIVE: To determine the potential procholinergic nature of some of the commonly used drugs by examining their cholinesterase inhibiting properties. METHODS: The Ellman spectrophotometric method was used with human acetylcholinesterase and butyrylcholinesterase, in the absence and presence of increasing concentrations of each test drug. To compare inhibition potencies, from enzyme kinetic data, we determined half maximal inhibitory concentration (IC(50) values) for each cholinesterase by each drug. RESULTS: Of the 28 drugs examined, over half (17/28) inhibited one or both of the human cholinesterases. The inhibition potencies were often within 1 to 2 orders of magnitude of reversible cholinesterase inhibitors currently used to treat Alzheimer's disease. These included trazodone, quetiapine, risperidone, indapamide, and perindopril. CONCLUSIONS: Many drugs used by older adults for other reasons have potentially clinically relevant procholinergic effects. The effect of cumulative cholinesterase inhibition merits clinical evaluation.
Impact of a medication management system on nursing home admission rate in a community-dwelling nursing home-eligible Medicaid population.
Schulz RM, Porter C, Lane M … +2 more , Cornman C, Branham L
Am J Geriatr Pharmacother · 2011 Feb · PMID 21459310 · Publisher ↗
BACKGROUND: Community-dwelling frail elderly have an increased need for effective medication management to reside in their homes and delay or avoid admission to nursing homes. OBJECTIVE: The objective of this study was t...
BACKGROUND: Community-dwelling frail elderly have an increased need for effective medication management to reside in their homes and delay or avoid admission to nursing homes. OBJECTIVE: The objective of this study was to examine the impact of a medication management system on nursing home admission within the community-dwelling frail elderly. METHODS: This prospective cohort study compared nursing home admission rates in intervention and control clients of a state Medicaid home and community-based waiver program. Groups were matched on age (±5 years), race, gender, and waiver program start date (±120 days). The medication management service consisted of 2 parts: 1) prescription medicines dispensed from the client's local pharmacy in a calendar card, and 2) a coordinating service by a health educator to address medication-related problems as they arose. The primary dependent variable was admission to a nursing home. RESULTS: A total of 273 clients agreed to participate, enrolled, and had at least 1 prescription dispensed. The matched control group was composed of 800 other clients. The client sample was 72 years of age, 73% (785/1073) non-white, 75% (804/1073) female, and enrolled in the waiver program approximately 50 months. The 2 groups were similar on all demographic variables examined. Six clients (2.2%) in the intervention group and 40 clients (5.0%) in the control group were admitted to a nursing home at least once during the study period. Logistic regression was used to test the model predicting at least 1 nursing home admission. Control group clients were 2.94 times more likely to be admitted to a nursing home than clients in the intervention group. CONCLUSIONS: The medication management service implemented within this study was effective in reducing nursing home admissions in a group of frail community-dwelling elderly.
Intervention to decrease glyburide use in elderly patients with renal insufficiency.
Aspinall SL, Zhao X, Good CB … +14 more , Stone RA, Boresi J, Cox S, Bartholomew C, Jansen D, Guterman S, Patino M, Rivera-Miranda G, Burlingame M, Frazer J, Sellers J, Stanard Steele V, Witt L, Cunningham FE
Am J Geriatr Pharmacother · 2011 Feb · PMID 21459309 · Publisher ↗
OBJECTIVES: The objectives of this study were to describe changes in glyburide prescribing in cohorts that were and were not targeted by a risk reduction project, assess factors associated with glyburide discontinuation,...
OBJECTIVES: The objectives of this study were to describe changes in glyburide prescribing in cohorts that were and were not targeted by a risk reduction project, assess factors associated with glyburide discontinuation, and evaluate changes in glycated hemoglobin (ie, HbA(1c)) levels and rates of serious hypoglycemia. METHODS: This historical cohort study included a targeted cohort of 4368 outpatient veterans aged ≥65 years with active prescriptions for glyburide between April 1, 2007 and June 30, 2007 and serum creatinine (SCr) ≥2 mg/dL and a nontargeted cohort of 1886 outpatients meeting these same criteria between July 1, 2007 and September 3, 2007. The intervention in the risk reduction project took place on September 4, 2007 and entailed giving regional pharmacy leaders information about the increased risk of hypoglycemia with glyburide and the list of targeted patients for follow up with providers. For each patient, the study period was the time between the date they first met the eligibility criteria and March 31, 2008. All data were obtained from Veterans Affairs (VA) administrative databases. The primary outcome was the discontinuation of glyburide. Secondary outcomes were the change in HbA(1c) after stopping glyburide and the rate of serious hypoglycemia after intervention. RESULTS: Incidence rate ratios (IRRs) for glyburide discontinuation in targeted versus nontargeted cohorts were statistically significantly elevated in September (IRR 2.1; 95% CI 1.7-2.5), October (IRR 1.3; 95% CI 1.1-1.6), and November 2007 (IRR 1.4; 95% CI 1.1-1.7). The intervention, black race, SCr, Charlson comorbidity score, new glyburide use, and VA region were independently associated with discontinuation. Among patients in the targeted cohort who discontinued glyburide, mean (SD) HbA(1c) at baseline and after discontinuation were 7.17% (1.35%), and 7.22% (1.34%), respectively (P = 0.36). The hypoglycemia rates/1000 person-days were 0.093 before the intervention and 0.070 afterwards (P = 0.10). CONCLUSION: A one-time intervention in a risk reduction project decreased glyburide use over a 3-month period in elderly outpatients with renal insufficiency without compromising glucose control.
Elderly people's knowledge of the purpose of their medicines.
Guénette L, Moisan J
Am J Geriatr Pharmacother · 2011 Feb · PMID 21459308 · Publisher ↗
BACKGROUND: It is generally believed that elderly persons know little about the purpose of their medications. However, researchers have reported contradictory results. Moreover, little is known about which patient charac...
BACKGROUND: It is generally believed that elderly persons know little about the purpose of their medications. However, researchers have reported contradictory results. Moreover, little is known about which patient characteristics are associated with knowledge of a drug's purpose. OBJECTIVES: To assess whether community-dwelling elderly persons could correctly identify the general purpose of their prescription and nonprescription drugs and to examine the link between participant and drug characteristics and this knowledge. METHODS: During an in-home interview, a random sample of pharmacy clients aged ≥65 years were asked to report all the drugs they had taken over the previous 30 days and to state the reasons for their use. Drugs were classified according to the anatomical therapeutic chemical (ATC) classification system. We looked for any information in the stated reasons that concerned the anatomical system, organs and diseases. We assumed that the person knew the general purpose of the drug if the reason stated referred to the anatomical system targeted by the drug. A multivariate logistic regression model was used to identify participant characteristics that were associated with knowledge. RESULTS: We interviewed 193 seniors who reported using 1645 drugs that could be classified according to the ATC classification system. Of those drugs, 1364 (82.9%) were self reported as physician prescribed. Among participants, 134 (69.4%) knew the general purpose of all drugs they reported. Characteristics associated with knowledge of the purpose were female gender (adjusted odds ratios [ORs], 3.3, 95% confidence intervals [CI] 1.5-7.1), normal cognition (adjusted OR, 5.0; 95% CI, 2.0-12.8), and average to superior socioeconomic status (adjusted OR, 2.7, 95% CI, 1.2-6.3). Knowledge was slightly better for nonprescribed drugs than for prescribed drugs (overall proportion of appropriate reasons: 96.1% vs 91.1%; P < 0.01). CONCLUSIONS: Community-dwelling elderly persons have a good knowledge of the general purpose of their prescription and nonprescription drugs.
Identification, pharmacologic considerations, and management of prostatitis.
Schiller DS, Parikh A
Am J Geriatr Pharmacother · 2011 Feb · PMID 21459307 · Publisher ↗
BACKGROUND: Prostatitis is a collection of signs and symptoms that occur as a result of inflammation or swelling of the prostate gland. There are many different causes for prostatitis, including infection; occasionally n...
BACKGROUND: Prostatitis is a collection of signs and symptoms that occur as a result of inflammation or swelling of the prostate gland. There are many different causes for prostatitis, including infection; occasionally no clear etiology for the inflammation is found. Effective treatment often depends on identification of the cause, but a microbiologic organism is not always detectable, especially in cases of chronic prostatitis. OBJECTIVE: The aim of this article was to review identification and treatment options for prostatitis, including pharmacologic and nonpharmacologic interventions. METHODS: Relevant information was identified through a search of MEDLINE (1966-June 2010), International Pharmaceutical Abstracts (1970-June 2010), and EMBASE (1947-June 2010). Randomized, controlled trials that examined prostate cancer, benign prostatic hypertrophy, or procedures related to the prostate (ie, biopsies) were excluded. RESULTS: A working classification system for prostatitis was developed in 1999, but there are few randomized controlled trials that distinguish between the various treatment options. Bacterial prostatitis can be acute or chronic but always requires some degree of antimicrobial therapy. Pharmacologic features of fluoroquinolones make them the preferred agents for most patients. These antibiotics can become trapped in a chronically inflamed prostate due to pH differences between prostatic tissue and serum. Many fluoroquinolones have penetration ratios (prostate level:serum level) of up to 4:1. A study in European men (N = 117) who received levofloxacin 500 mg/d with a diagnosis of chronic bacterial prostatitis demonstrated clinical success rates of 92% (95% CI 84.8%-96.5%), 77.4% (95% CI, 68.2-84.9%), 66.0% (95% CI, 56.2%-75.0%), and 61.9% (95% CI, 51.9%-71.2%) at 5-12 days, 1 month, 3 months, and 6 months after treatment. Additionally, there have been numerous randomized, placebo-controlled trials in patients with chronic prostatitis that have studied α-blockers, steroid inhibitors, anti-inflammatory agents, and bioflavonoids. Treatment responses to α-blockers appear to be greater with longer durations of therapy in α-blocker-naïve patients (National Institutes of Health-Chronic Prostatitis Symptom Index [NIH-CPSI] score reduction of at least 3.6 points after 6 weeks of tamsulosin therapy [P = 0.04] and up to 14.3 and 9.9 point NIH-CPSI score reductions with 14 weeks of terazosin and 24 weeks of alfuzosin therapy, respectively [P = 0.01 for both]). Combination therapy with an α-blocker, an anti-inflammatory, and a muscle relaxant does not appear to offer significant advantages over monotherapy (12.7 vs 12.4 point reduction in NIH-CPSI scores) and a stepwise approach to therapy involving antibiotics followed by bioflavonoids and then α-blockers appears to effectively reduce symptoms for up to 1 year in patients with chronic prostatitis (mean NIH-CPSI point reduction of 9.5 points compared with baseline, P < 0.0001). Patients who have had multiple unsuccessful treatment regimens may benefit from direct stimulation of the pelvic muscles through electromagnetic or electroacupuncture therapy. CONCLUSIONS: Prostatitis can resemble various other medical conditions but proper classification and an understanding of the pharmacologic features and expectations of the medications used to treat it can help identify effective treatment strategies. Fluoroquinolones are the preferred agents for treating bacterial causes of prostatitis and have demonstrated efficacy in some cases of chronic prostatitis when an organism has not been identified. However, the use of agents with anti-inflammatory or antiadrenergic properties may be necessary in combination with or after trying antimicrobial agents.
Insulin therapy in the elderly patient with diabetes.
Tanwani LK
Am J Geriatr Pharmacother · 2011 Feb · PMID 21459306 · Publisher ↗
BACKGROUND: Most elderly patients with type 2 diabetes require, or will eventually require, insulin to achieve or maintain their glycemic goals. However, insulin therapy remains underused in this population. OBJECTIVE: T...
BACKGROUND: Most elderly patients with type 2 diabetes require, or will eventually require, insulin to achieve or maintain their glycemic goals. However, insulin therapy remains underused in this population. OBJECTIVE: The goal of this review is to evaluate the role of insulin therapy in elderly patients and identify strategies to improve its use in this patient population. METHODS: Searches of the MEDLINE and EMBASE databases were conducted to identify papers published in English between January 1990 and March 2010. The following search terms were used: diabetes mellitus, insulin, elderly, geriatric, analog, premix, pen device, and human insulin. Papers selected for review included meta-analyses, randomized controlled trials of insulin therapy, or evidence-based reviews and/or expert opinion regarding the use of insulin in elderly patients with diabetes. RESULTS: Insulin therapy is the most effective antidiabetic agent when appropriately dosed; however, only a minority of elderly patients with diabetes uses it. Although there are few randomized controlled studies on insulin use in the elderly, an individualized approach to insulin therapy is recommended to account for varying clinical and practical factors that affect diabetes care in this patient population. Therapy with insulin analogs offers several advantages compared with human insulin regimens, including a more physiologic pharmacologic profile, increased convenience, and a reduced risk of hypoglycemia, which may make them particularly attractive in older adults. Premixed insulin analog therapy may provide added convenience, as well as improved glycemic control. Insulin pen devices are also recommended to facilitate insulin dosing and help patients maintain their independence. CONCLUSIONS: The improved clinical profiles of insulin analogs and the ease of use of newer insulin delivery devices may be advantageous in elderly patients with diabetes; however, additional research on the efficacy and safety of insulin regimens is urgently needed.
A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity.
Gellad WF, Grenard JL, Marcum ZA
Am J Geriatr Pharmacother · 2011 Feb · PMID 21459305 · Full text
BACKGROUND: Medication nonadherence is a common problem among the elderly. OBJECTIVE: To conduct a systematic review of the published literature describing potential nonfinancial barriers to medication adherence among th...
BACKGROUND: Medication nonadherence is a common problem among the elderly. OBJECTIVE: To conduct a systematic review of the published literature describing potential nonfinancial barriers to medication adherence among the elderly. METHODS: The PubMed and PsychINFO databases were searched for articles published in English between January 1998 and January 2010 that (1) described "predictors," "facilitators," or "determinants" of medication adherence or that (2) examined the "relationship" between a specific barrier and adherence for elderly patients (ie, ≥65 years of age) in the United States. A manual search of the reference lists of identified articles and the authors' files and recent review articles was conducted. The search included articles that (1) reviewed specific barriers to medication adherence and did not solely describe nonmodifiable predictors of adherence (eg, demographics, marital status), (2) were not interventions designed to address adherence, (3) defined adherence or compliance and specified its method of measurement, and (4) involved US participants only. Nonsystematic reviews were excluded, as were studies that focused specifically on people who were homeless or substance abusers, or patients with psychotic disorders, tuberculosis, or HIV infection, because of the unique circumstances that surround medication adherence for each of these populations. RESULTS: Nine studies met inclusion criteria for this review. Four studies used pharmacy records or claims data to assess adherence, 2 studies used pill count or electronic monitoring, and 3 studies used other methods to assess adherence. Substantial heterogeneity existed among the populations studied as well as among the measures of adherence, barriers addressed, and significant findings. Some potential barriers (ie, factors associated with nonadherence) were identified from the studies, including patient-related factors such as disease-related knowledge, health literacy, and cognitive function; drug-related factors such as adverse effects and polypharmacy; and other factors including the patient-provider relationship and various logistical barriers to obtaining medications. None of the reviewed studies examined primary nonadherence or nonpersistence. CONCLUSION: Medication nonadherence in the elderly is not well described in the literature, despite being a major cause of morbidity, and thus it is difficult to draw a systematic conclusion on potential barriers based on the current literature. Future research should focus on standardizing medication adherence measurements among the elderly to gain a better understanding of this important issue.
Year in review: medication mishaps in the elderly.
Peron EP, Marcum ZA, Boyce R … +2 more , Hanlon JT, Handler SM
Am J Geriatr Pharmacother · 2011 Feb · PMID 21459304 · Full text
OBJECTIVE: This paper reviews articles from 2010 that examined medication mishaps (ie, medication errors and adverse drug events [ADEs]) in the elderly. METHODS: The MEDLINE and EMBASE databases were searched for English...
OBJECTIVE: This paper reviews articles from 2010 that examined medication mishaps (ie, medication errors and adverse drug events [ADEs]) in the elderly. METHODS: The MEDLINE and EMBASE databases were searched for English-language articles published in 2010 using a combination of search terms including medication errors, medication adherence, medication compliance, suboptimal prescribing, monitoring, adverse drug events, adverse drug withdrawal events, therapeutic failures, and aged. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional publications. Five studies of note were selected for annotation and critique. From the literature search, this paper also generated a selected bibliography of manuscripts published in 2010 (excluding those previously published in the American Journal of Geriatric Pharmacotherapy or by one of the authors) that address various types of medication errors and ADEs in the elderly. RESULTS: Three studies focused on types of medication errors. One study examined underuse (due to prescribing) as a type of medication error. This before-and-after study from the Netherlands reported that those who received comprehensive geriatric assessments had a reduction in the rate of undertreatment of chronic conditions by over one third (from 32.9% to 22.3%, P < 0.05). A second study focused on reducing medication errors due to the prescribing of potentially inappropriate medications. This quasi-experimental study found that a computerized provider order entry clinical decision support system decreased the number of potentially inappropriate medications ordered for patients ≥ 65 years of age who were hospitalized (11.56 before to 9.94 orders per day after, P < 0.001). The third medication error study was a cross-sectional phone survey of managed-care elders, which found that more blacks than whites had low antihypertensive medication adherence as per a self-reported measure (18.4% vs 12.3%, respectively; P < 0.001). Moreover, blacks used more complementary and alternative medicine (CAM) than whites for the treatment of hypertension (30.5% vs 24.7%, respectively; P = 0.005). In multivariable analyses stratified by race, blacks who used CAM were more likely than those who did not to have low antihypertensive medication adherence (prevalence rate ratio = 1.56; 95% CI, 1.14-2.15; P = 0.006). The remaining two studies addressed some form of medication-related adverse patient events. A case-control study of Medicare Advantage patients revealed for the first time that the use of skeletal muscle relaxants was associated significantly with an increased fracture risk (adjusted odds ratio = 1.40; 95% CI, 1.15-1.72; P < 0.001). This increased risk was even more pronounced with the concomitant use of benzodiazepines. Finally, a randomized controlled trial across 16 centers in France used a 1-week educational intervention about high-risk medications and ADEs directed at rehabilitation health care teams. Results indicated that the rate of ADEs in the intervention group was lower than that in the usual care group (22% vs 36%, respectively, P = 0.004). CONCLUSION: Information from these studies may advance health professionals' understanding of medication errors and ADEs and may help guide research and clinical practices in years to come.
Extrapyramidal symptoms with concomitant use of amitriptyline and amiodarone in an elderly patient.
Pawar PS, Woo DA
Am J Geriatr Pharmacother · 2010 Dec · PMID 21356508 · Publisher ↗
BACKGROUND: Amitriptyline is a tricyclic antidepressant useful for the treatment of depression. Amiodarone is a class III antiarrhythmic agent used for the treatment of cardiac dysrhythmias. OBJECTIVE: The objective of t...
BACKGROUND: Amitriptyline is a tricyclic antidepressant useful for the treatment of depression. Amiodarone is a class III antiarrhythmic agent used for the treatment of cardiac dysrhythmias. OBJECTIVE: The objective of the current report is to describe the case of a previously asymptomatic patient receiving amitriptyline who developed extrapyramidal symptoms within 1 month of initiating concomitant treatment with amiodarone for atrial fibrillation. CASE SUMMARY: An 82-year-old, right-handed, white woman was brought to the medical center's emergency department with speech difficulty suggesting stroke. She was noted to have continuous orobuccal dyskinesias, upper and lower extremity shaking, and dry mouth. Once it was determined that no other focal neurologic findings indicated stroke, her medications were reviewed. The patient had been taking amitriptyline 50 mg/d for the past year for insomnia without any adverse events. However, 1 month before presentation, she also initiated treatment with amiodarone 200 mg/d for atrial fibrillation and had developed the symptoms of concern shortly thereafter. The patient's amitriptyline treatment was discontinued and she received benzotropine for extrapyramidal symptoms from amitriptyline toxicity. She experienced complete resolution of dysarthric speech and limb shaking within 2 days. A total score of 7 was achieved using Naranjo's adverse drug reaction causality algorithm, suggesting amitriptyline was a probable cause of these adverse events. CONCLUSION: This was a probable case of extrapyramidal symptoms in an elderly woman who began using amiodarone while also taking amitriptyline.
A taxonomy of reasons for not prescribing guideline-recommended medications for patients with heart failure.
Steinman MA, Patil S, Kamat P … +2 more , Peterson C, Knight SJ
Am J Geriatr Pharmacother · 2010 Dec · PMID 21356507 · Full text
BACKGROUND: Performance-measurement systems may work best when they account for the reasons why physicians do not provide guideline-recommended interventions. OBJECTIVE: This article develops a conceptual framework for u...
BACKGROUND: Performance-measurement systems may work best when they account for the reasons why physicians do not provide guideline-recommended interventions. OBJECTIVE: This article develops a conceptual framework for understanding the proximate, patient-centered reasons why physicians do not prescribe angiotensin-converting enzyme (ACE) inhibitors or β-blockers to patients with heart failure and reduced systolic function. METHODS: This was a focus group study using a 2-stage design. Academically affiliated clinicians of different specialties and levels of training were recruited by e-mailed invitations sent to clinicians within each target group. To be included, candidates needed to be currently practicing in an ambulatory care setting in which they encountered patients with heart failure. In the first part of each group, participants were asked to describe reasons for not prescribing ACE inhibitors or â-blockers for patients with heart failure. Next, participants were asked to develop concept maps that organized these reasons into categories and described the relationships between these categories. The concept maps from each group were synthesized to develop a consensus scheme for categorizing reasons for nonprescribing. RESULTS: There were 31 participants in 7 focus groups; median age was 31 years and 55% (17/31) were women. Two broad themes emerged. First, clinicians hinted at their own attitude-related barriers to prescribing. However, they framed their comments largely in terms of patient-centered reasons for nonprescribing that arose in individual patient encounters. Second, decision making about heart failure drug therapy often involved a complex and overlapping series of considerations. Five categories of reasons for not prescribing ACE inhibitors or â-blockers emerged: (1) adverse effects of drug therapy; (2) nonadherence to therapeutic and monitoring plan; (3) patients' preferences and beliefs; (4) comanagement and transitions of care; and (5) prioritization and patient benefit. CONCLUSIONS: Physicians' reasons for not prescribing guideline-recommended drugs for heart failure are complex but can be organized into a useful taxonomy. This taxonomy may be helpful for performance-measurement and quality-improvement programs that seek to understand reasons for physicians' nonadherence to guidelines.
Albuterol and levalbuterol use and spending in Medicare beneficiaries with chronic obstructive pulmonary disease.
Puig A, McElligott S, Bergquist H … +1 more , Doshi JA
Am J Geriatr Pharmacother · 2010 Dec · PMID 21356506 · Publisher ↗
BACKGROUND: The evidence for the benefits of branded levalbuterol over generic albuterol in patients with chronic obstructive pulmonary disease (COPD) is inconclusive. However, there are significant cost differences betw...
BACKGROUND: The evidence for the benefits of branded levalbuterol over generic albuterol in patients with chronic obstructive pulmonary disease (COPD) is inconclusive. However, there are significant cost differences between these products. OBJECTIVES: This study examined use and spending on albuterol and levalbuterol in a nationally representative sample of Medicare beneficiaries with COPD enrolled in Part D in 2006. It also examined differences in patient characteristics and use of other COPD drugs among recipients of these 2 short-acting β-agonists. METHODS: Data were obtained from the 5% Medicare files for 2005-2006 linked to the 2006 Medicare Part D files. The sample consisted of all fee-for-service beneficiaries with COPD enrolled in stand-alone Part D plans in 2006. Patient characteristics and other COPD medication use were compared across albuterol-only users, levalbuterol-only users, and users of both albuterol and levalbuterol. Multinomial logistic regressions were used to identify factors independently associated with levalbuterol use. RESULTS: There were 5.5 times more albuterol users than levalbuterol users in 2006; however, mean annual spending on levalbuterol was 18.6 times higher per user in 2006 than spending on albuterol ($1876 vs $101 per user, respectively). Levalbuterol-only users were more likely to be older than albuterol-only users (mean age: 71.5 vs 68.7 years; P < 0.05), as well as sicker (mean prescription drug hierarchical condition category score: 1.72 vs 1.55; P < 0.05) and residing in the South (67.9% vs 41.6%; P < 0.05). Levalbuterol-only users were more likely to use nebulizer forms covered under Part B than inhaler forms covered under Part D (78.6% vs 26.8%, respectively; P < 0.05), whereas albuterol-only users were more likely to use inhaler forms covered under Part D than nebulizer forms covered under Part B (82.2% vs 33.0%, respectively; P < 0.05). CONCLUSIONS: In this sample of Medicare beneficiaries with COPD enrolled in Part D, mean annual spending in 2006 was significantly higher for levalbuterol than for albuterol. The differences between levalbuterol and albuterol users in terms of patient characteristics, geographic region, and drug formulation/device type, coupled with the inconclusive evidence for efficacy differences in the literature, highlight the need for further comparative clinical and cost-effectiveness studies of these agents.
Incident use and outcomes associated with potentially inappropriate medication use in older adults.
Dedhiya SD, Hancock E, Craig BA … +2 more , Doebbeling CC, Thomas J
Am J Geriatr Pharmacother · 2010 Dec · PMID 21356505 · Publisher ↗
BACKGROUND: Most studies of potentially inappropriate medication (PIM) use among older adults have focused on prevalence rather than incidence. OBJECTIVES: The goals of this study were to determine the 1-year incidence o...
BACKGROUND: Most studies of potentially inappropriate medication (PIM) use among older adults have focused on prevalence rather than incidence. OBJECTIVES: The goals of this study were to determine the 1-year incidence of PIM use among elderly Indiana Medicaid residents of nursing homes and to examine associations between incident PIM use and hospitalization and mortality. METHODS: A retrospective analysis was conducted using Indiana Medicaid enrollment and administrative claims files. Individuals were included if they were Medicaid eligible and aged ≥65 years as of January 2003 and received nursing home services in each month of 2003 or until death in 2003. Individuals also had to receive nursing home services from October 2002 through December 2002 for inclusion in the sample. To focus analysis on incident PIM use, individuals who received any PIM prescription medication from October 2002 through December 2002 were excluded from the sample, as were those not prescribed any new medication in 2003. PIMs were identified using the 2003 Beers criteria. Associations between incident PIM use and hospitalization and mortality were assessed using logistic regression models after controlling for other risk factors. Potential selection bias was examined using bivariate probit models. RESULTS: The study sample consisted of 7594 individuals (mean age, 83.07 years). A majority of the sample was female (76.5%), white (89.7%), and widowed (58.8%). Most individuals received care in nursing homes located in urban areas (5306 [69.9%]) and in the central region of Indiana (2838 [37.4%]). One-year incidence of PIM use was 42.1%. Incident PIM users were more likely to be hospitalized (odds ratio [OR] = 1.27; 95% CI, 1.10-C1.46) and more likely to die (OR = 1.46; 95% CI, 1.31-C1.62) in the 12 months after first receiving a PIM than nonusers, even after adjusting for demographic and clinical risk factors. CONCLUSIONS: Incident PIM use was high among these elderly Indiana Medicaid residents of nursing homes. Individuals who began use of a PIM were at a higher risk of hospitalization and of dying.
Safety and clinical outcomes among older adults receiving daptomycin therapy: Insights from a patient registry.
DePestel DD, Hershberger E, Lamp KC … +1 more , Malani PN
Am J Geriatr Pharmacother · 2010 Dec · PMID 21356504 · Publisher ↗
BACKGROUND: Serious gram-positive bacterial infections are an important cause of morbidity and mortality among older adults and can present significant challenges to clinicians. Data evaluating the safety and effectivene...
BACKGROUND: Serious gram-positive bacterial infections are an important cause of morbidity and mortality among older adults and can present significant challenges to clinicians. Data evaluating the safety and effectiveness of newer agents in this population are limited. OBJECTIVE: Daptomycin is a lipopeptide with activity against resistant gram-positive organisms. To better understand the overall safety and effectiveness of daptomycin in older adults (≥66 years of age), the authors reviewed the data that were collected as part of an ongoing registry maintained by Cubist Pharmaceuticals, Inc. (Lexington, Massachusetts), the manufacturer of daptomycin. METHODS: The Cubicin Outcomes Registry and Experience (CORE) is a multicenter, retrospective registry designed to collect postmarketing clinical data on patients who received daptomycin. The CORE data collected from 58 institutions across the United States between January 1, 2005, and December 31, 2007, were analyzed to better understand the overall safety profile of daptomycin and the clinical outcomes of older adults who were treated with this agent. Patients were considered to be nonevaluable if the medical record did not contain sufficient information to determine response at the end of therapy. Nonevaluable patients were excluded from the clinical outcome analysis but included in the safety analysis. RESULTS: The registry contained 1073 patients aged ≥66 years who received daptomycin; 23.8% (255/1073) were ≥81 years of age. Overall, 18.1% (194/1073) of patients experienced 324 adverse events, and 6.2% (67/1073) of patients experienced 97 adverse events that were considered possibly related to treatment with daptomycin. The most frequently reported adverse events that were considered possibly treatment related included creatine phosphokinase (CPK) elevations, gastrointestinal disorders, and skin rashes. Among the 67 patients who experienced ≥1 adverse event that was possibly related to daptomycin, 30 discontinued therapy due to the adverse event (13 due to CPK elevation). Overall, 78.7% (844/1073) of patients were considered evaluable for clinical outcomes. The clinical success rate for all evaluable patients was 90.2% (761/844). The success rate for evaluable patients ≥81 years of age (88.6% [171/193]) was comparable to that of the overall population. CONCLUSION: Experience with daptomycin in this group of older adults suggests good tolerability and clinical outcomes that are consistent with the results of other studies published to date.
A review of laxative therapies for treatment of chronic constipation in older adults.
Fleming V, Wade WE
Am J Geriatr Pharmacother · 2010 Dec · PMID 21356503 · Publisher ↗
BACKGROUND: Multiple studies have addressed the treatment of chronic constipation in adults in general; however, less guidance is available for treating this condition in older patients. OBJECTIVE: The aim of this paper...
BACKGROUND: Multiple studies have addressed the treatment of chronic constipation in adults in general; however, less guidance is available for treating this condition in older patients. OBJECTIVE: The aim of this paper was to review the effectiveness of laxatives for chronic constipation in the elderly. METHODS: Medline, Web of Science, international Pharmaceutical Abstracts, and the Cochrane database of Systematic Reviews were searched for english-language articles evaluating the treatment of chronic constipation in older individuals from the inception of the databases until October 2010. Search terms included constipation, treatment, laxative, elderly, and geriatric. Articles were excluded if the mean age was <65 years. RESULTS: Thirty-one trials were identified. These studies varied widely in terms of methodology, quality, sample size, efficacy end points, and duration. Mean stool frequency was 9.08 bowel movements per week with psyllium and 8.29 per week with calcium polycarbophil (P = 0.04). docusate sodium daily, docusate sodium q12h, and docusate calcium daily for 3 weeks produced a mean stool frequency of 1.95 bowel movements per week versus 1.50 for placebo (P = NS), 2.29 versus 1.76 (P = NS), and 2.83 versus 1.75 (P<0.02), respectively. Mean stool frequency with lactulose versus placebo was 0.7 and 0.5 bowel movements per day (P<0.02). in patients receiving polyethylene glycol or lactulose, mean stool frequency was 1.3 and 0.9 bowel movements per day (P = 0.005). in a study comparing senna plus a bulking agent with lactulose, mean stool frequency was 4.5 per week for the combination product versus 2.2 per week for lactulose (P<0.001). A study comparing sodium picosulfate with senna reported a mean stool frequency of 0.71 and 0.63 per day (P value not reported). Lubiprostone was associated with 5.69 spontaneous bowel movements per week versus 3.46 per week for placebo (P = 0.001). CONCLUSIONS: Higher-quality trials evaluating the treatment of constipation in older patients are needed to create a basis for more definitive recommendations in this population. The approach to older adults with constipation should be individualized.
Treatment of skin and soft tissue infections in the elderly: A review.
Kish TD, Chang MH, Fung HB
Am J Geriatr Pharmacother · 2010 Dec · PMID 21356502 · Publisher ↗
BACKGROUND: Skin and soft tissue infections (SSTIs) have become the second most common type of infection among persons residing in long-term care facilities. OBJECTIVE: The purpose of this article was to review the lates...
BACKGROUND: Skin and soft tissue infections (SSTIs) have become the second most common type of infection among persons residing in long-term care facilities. OBJECTIVE: The purpose of this article was to review the latest information on SSTIs among the elderly, including age-related changes, challenges, and treatment strategies in the era of emerging bacterial resistance. METHODS: Relevant information was identified through a search of MEDLINE (1970-April 2010), International Pharmaceutical Abstracts (1970-April 2010), and Google Scholar using the terms skin and soft tissue infection, skin and skin structure infection, cellulitis, treatment guidelines, and elderly. Additional publications were found by searching the reference lists of the identified articles. Trials published since 1970 were selected for this review if they prospectively evaluated mostly adults (≥18 years of age), included >50 patients, and reported diagnostic criteria as well as clinical outcomes in patients treated for simple or complicated SSTIs. RESULTS: Fifty-eight of 664 identified studies were selected and included in this review. A search of the literature did not identify any prospective clinical trials that were conducted exclusively in the elderly. Information on the treatment of SSTIs in the elderly was based solely on clinical studies that were conducted in adults in general. As recommended by the Infectious Diseases Society of America (IDSA) 2008 update, SSTIs should be suspected in elderly patients who have skin lesions and present with a decline in functional status, with or without fever. Patients who present with symptoms of systemic toxicity should be hospitalized for further evaluation. Current challenges in the management of SSTIs include the rapid emergence of community-acquired, methicillin-resistant Staphylococcus aureus (CA-MRSA), the emergence of macrolide-resistant streptococci within the past decade, and the lack of a reliable algorithm to differentiate potentially life-threatening SSTIs that require aggressive interventions and prompt hospitalization from those that can be managed in an outpatient setting. S aureus was the most common cause of SSTIs, being isolated in 42.8% (5015/11,723) of wounds, followed by streptococci. Common SSTIs in the elderly such as shingles, diabetic foot infections, infected pressure ulcers, and scabies, and their treatment were also discussed. Based on reviews of published trials, treatment of simple SSTIs generally consisted of administration of agents with activity against S aureus and Streptococcus species such as a penicillinase-resistant β-lactam, a first-generation cephalosporin, or clindamycin. Broadening of the antimicrobial spectrum to include gram-negative and anaerobic organisms should be implemented for complicated SSTIs such as diabetic foot infections and infected pressure ulcers. Local rates of MRSA, CA-MRSA, and macrolide-resistant streptococci should be considered when selecting empiric therapy. CONCLUSIONS: A search of the literature did not identify any prospective clinical trials on the treatment of SSTIs in the elderly; therefore, it is recommended to follow treatment based on the current IDSA guidelines. More research and publications are needed to establish proper selection of antimicrobial agents, treatment strategies, and duration of therapy of SSTIs in the elderly population.
Medicare Part D data: A valuable tool for pharmacoepidemiology and pharmacoeconomic research.
Hanlon JT, Donohue J
Am J Geriatr Pharmacother · 2010 Dec · PMID 21356501 · Publisher ↗
Abstract loading — click title to view on PubMed.
A comparison of four methods to quantify the cumulative effect of taking multiple drugs with sedative properties.
Taipale HT, Hartikainen S, Bell JS
Am J Geriatr Pharmacother · 2010 Oct · PMID 21335299 · Publisher ↗
BACKGROUND: Older people (ie, those aged >65 years) often use multiple drugs with sedative properties. These include drugs for intentional sedation and drugs that have sedation as an adverse reaction. Recent pharmacoepid...
BACKGROUND: Older people (ie, those aged >65 years) often use multiple drugs with sedative properties. These include drugs for intentional sedation and drugs that have sedation as an adverse reaction. Recent pharmacoepidemiologic studies have investigated the risks of multiple or combined sedative drug use. OBJECTIVE: The purpose of this commentary was to describe, compare, and discuss 4 previously published pharmacoepidemiologic methods used to quantify the cumulative effect of taking multiple drugs with sedative properties. METHODS: A MEDLINE literature search was conducted in January 2010 using Medical Subject Headings and the following search terms: hypnotics, sedatives, benzodiazepines, GAGA-A receptors, model, load, measurement, index, burden, system, and aged. The search was limited to English language, humans, and the year 2000 until present. Reports of methods that involved simply counting the number of sedative or psychotropic drugs, or described sedative drug use in anesthesia, were excluded. The search identified 4 methods. Research articles that have cited the descriptions of the 4 methods were retrieved using MEDLINE, Google Scholar, Scopus, and the Web of Science. RESULTS: The literature search identified 14 studies describing the use of 4 different methods to quantify the cumulative effect of taking multiple drugs with sedative properties. The 4 methods are the sedative load model, the Sloane model, the Drug Burden Index, and the central nervous system drug model. The methods differed with respect to the specific drugs or drug classes considered, the sedative ratings assigned to each drug, the inclusion or exclusion of drug dose in the model, and each model's likely ease of use in clinical practice. Adverse outcomes associated with taking multiple drugs with sedative properties included impaired physical and cognitive function, and an increased risk of falls. CONCLUSIONS: Evidence is accumulating in relation to a range of adverse outcomes associated with using multiple drugs with sedative properties. However, no studies have been conducted using>1 method to quantify the cumulative effect of taking multiple drugs with sedative properties. Each method has likely advantages and disadvantages. The usefulness of each method in clinical practice remains to be determined. The models must be validated in different populations of older people and may subsequently need to be refined.
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