The American Journal Of Geriatric Pharmacotherapy[JOURNAL]
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200 papers
Evaluation of the effects of galantamine on cardiac function in elderly patients with Alzheimer's disease.
Isik AT, Bozoglu E, Naharci MI … +1 more , Kilic S
Am J Geriatr Pharmacother · 2010 Oct · PMID 21335298 · Publisher ↗
BACKGROUND: Galantamine, a cholinesterase inhibitor, is used as a first-line drug in the treatment of Alzheimer's disease (AD). However, it may have vagotonic effects, which may cause bradycardia and/or heart block in pa...
BACKGROUND: Galantamine, a cholinesterase inhibitor, is used as a first-line drug in the treatment of Alzheimer's disease (AD). However, it may have vagotonic effects, which may cause bradycardia and/or heart block in patients with or without a history of cardiac disease. OBJECTIVE: The purpose of this study was to evaluate the effects of galantamine on electrophysiology and arterial blood pressure in elderly patients with AD. METHODS: From March 2008 through August 2009, consecutive patients ≥65 years of age were approached for enrollment and underwent a comprehensive geriatric assessment. Patients with newly diagnosed AD who were enrolled in the study were treated with galantamine extended-release capsules using a 2- to 4-week titration schedule. The starting dosage was 8 mg once daily. After 2 to 4 weeks on the initial dosage, the dosage was increased to 16 mg once daily. After another 2 to 4 weeks, if galantamine was still well tolerated, the dosage was increased to 24 mg once daily. ECG parameters and blood pressure were recorded at baseline and at each galantamine dose level (8, 16, and 24 mg/d); blood pressure was measured once daily. The study lasted -4 months after baseline assessment. RESULTS: Sixty-four patients with newly diagnosed AD were enrolled in the study, 51 of whom completed the study (28 women and 23 men; mean age, 78.5 years). No significant changes relative to baseline occurred in any of the ECG parameters or arterial blood pressure at any of the investigated dosages of galantamine. CONCLUSION: None of the dosages of galantamine investigated in this study significantly altered ECG parameters or arterial blood pressure (relative to baseline) in these elderly patients with AD.
Impact of maintenance therapy on hospitalization and expenditures for Medicare beneficiaries with chronic obstructive pulmonary disease.
Stuart BC, Simoni-Wastila L, Zuckerman IH … +7 more , Davidoff A, Shaffer T, Yang HW, Qian J, Dalal AA, Mapel DW, Bryant-Comstock L
Am J Geriatr Pharmacother · 2010 Oct · PMID 21335297 · Publisher ↗
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with high levels of hospitalization and health care expenditures among the aged. Adherence to appropriate maintenance drug regimens has been reported...
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with high levels of hospitalization and health care expenditures among the aged. Adherence to appropriate maintenance drug regimens has been reported to reduce hospitalization and health care spending in clinical trials. However, little research has been conducted to compare use versus nonuse of these medications in terms of health-related outcomes in routine practice. OBJECTIVE: The purpose of this study was to compare differences between users and nonusers of maintenance medications in terms of selected outcomes for a nationally representative sample of Medicare beneficiaries with COPD. METHODS: The study sample was selected from Medicare Current Beneficiary Surveys conducted between 1997 and 2005. Beneficiaries with COPD who used ≥1 maintenance medication annually were compared with nonusers on 3 claims-based outcomes: any hospitalization, any rehospitalization within 31 days, and total annual Medicare expenditures. RESULTS: The study sample consisted of 6322 Medicare beneficiaries who contributed a total of 9161 person-year observations for analysis. Over the 9-year study period, 39.9% (3659/9161) of the person-year observations were recorded for maintenance medication users, and 60.1% (5502/9161) were recorded for nonusers. Most of the observations for medication users involved beneficiaries who were female (50.1% [1833/3659]), non-Hispanic white (85.4% [3124/3659]), and ≥65 years of age (88.2% [3228/3659]); most of the observations for nonusers involved beneficiaries who were male (51.9% [2855/5502]), non-Hispanic white (82.7% [4550/5502]), and ≥65 years of age (88.1% [4848/5502]). Annually, 40% of the sample filled prescriptions for COPD maintenance medications. In multivariate models, maintenance drug users were less likely than nonusers to be hospitalized (odds ratio [OR] = 0.70; 95% CI, 0.61 to 0.79) or rehospitalized (OR= 0.74; 95% CI, 0.63 to 0.87), and had significantly lower annual Medicare expenditures (-$3916; 95% CI, -$4977 to -$2854). CONCLUSIONS: In this comparison of users and nonusers of maintenance medication for COPD, use of maintenance therapy was associated with significantly lower risks of hospitalization and rehospitalization and reduced Medicare expenditures.
Impact of enhanced pharmacologic care on the prevention of falls: a randomized controlled trial.
Blalock SJ, Casteel C, Roth MT … +3 more , Ferreri S, Demby KB, Shankar V
Am J Geriatr Pharmacother · 2010 Oct · PMID 21335296 · Publisher ↗
BACKGROUND: Falls are the leading cause of both fatal and nonfatal injuries among older adults in the United States. Medications that affect the central nervous system are known to increase the risk of falling. OBJECTIVE...
BACKGROUND: Falls are the leading cause of both fatal and nonfatal injuries among older adults in the United States. Medications that affect the central nervous system are known to increase the risk of falling. OBJECTIVE: The purpose of this study was to assess the effects of a community pharmacy-based falls-prevention program targeting high-risk older adults on the rates of recurrent falls, injurious falls, and filling prescriptions for medications that have been associated with an increased risk of falling. METHODS: This was a randomized controlled trial of participants recruited through a community pharmacy chain in North Carolina. The 2-year study consisted of a 1-year "look-back" period before randomization and a 1-year follow-up period after randomization. Patients were eligible to participate if they were ≥65 years of age, had fallen at least once during the 1-year period preceding enrollment, and were taking medications associated with an increased risk of falling. Medications classified as high risk included benzodiazepines, antidepressants, anticonvulsants, sedative hypnotics, opioid analgesics, antipsychotics, and skeletal muscle relaxants. Participants were assigned to either the intervention arm or the control arm; participants in the intervention arm were invited to attend a face-to-face medication consultation conducted by a community pharmacy resident, whereas those in the control arm received no medication consultation. The primary end point was the rate of recurrent falls during the 1-year followup period. Secondary end points were the total number of prescriptions for high-risk medications filled during the follow-up period and either discontinued use or a reduction in the dosage of a high-risk medication during the follow-up period. RESULTS: One hundred eighty-six patients (132 women, 54 men; 88.7% white) were enrolled. Intention-to-treat (ITT) analyses revealed no significant differences in the rates of recurrent falls, injurious falls, or filling prescriptions for high-risk medications. However, 13 patients in the intervention group either discontinued use of a high-risk medication or had the dosage reduced during the follow-up period, compared with 5 patients in the control group (χ(2) = 3.94; P < 0.05). As-treated analyses revealed numeric reductions in the rates of falls (rate ratio [RR] = 0.76; 95% CI, 0.53-1.09), injurious falls (RR= 0.67; 95% CI, 0.43-1.05), and filling prescriptions for high-risk medications (RR= 0.85; 95% CI, 0.72-1.03) after receipt of the intervention, but the differences were not statistically significant. CONCLUSIONS: Results of this study support the feasibility of using community pharmacies to deliver a falls-prevention program targeting high-risk older adults. Although the ITT analyses revealed no significant reduction in the rate of recurrent falls, injurious falls, or overall use of high-risk medications, individuals in the intervention group were more likely than those in the control group to discontinue use of a high-risk medication or have the dosage reduced during the 1-year follow-up period. More work is needed to evaluate the intervention using a larger sample size that provides greater power to detect clinically meaningful effects of reduction in the use of high-risk medications on preventing or reducing falls in the high-risk population.
Use of digoxin for heart failure and atrial fibrillation in elderly patients.
Cheng JW, Rybak I
Am J Geriatr Pharmacother · 2010 Oct · PMID 21335295 · Publisher ↗
BACKGROUND: Digoxin has been reported to improve symptoms and reduce hospitalization in patients with heart failure as well as to control rapid ventricular rate in patients with atrial fibrillation. Both of these are hig...
BACKGROUND: Digoxin has been reported to improve symptoms and reduce hospitalization in patients with heart failure as well as to control rapid ventricular rate in patients with atrial fibrillation. Both of these are high-prevalence diseases in the elderly, and yet studies have indicated that digoxin may not be used appropriately in this population. Clinical trials evaluating digoxin use specifically in the elderly are scarce. OBJECTIVE: This article discusses the evidence on the therapeutic use of digoxin in the elderly and the changes in the pharmacokinetics of digoxin with aging to provide recommendations about the appropriate use of this drug in this population. METHODS: Peer-reviewed clinical trials, review articles, and relevant treatment guidelines limited to those evaluating patients aged >65 years were identified from MEDLINE and the Current Contents database (both from 1966 to May 1, 2010) using the search terms digoxin, pharmacokinetics, heart failure, and atrial fibrillation. Citations from available articles were also reviewed for additional references. RESULTS: One pharmacokinetic study, 8 clinical trials, and 2 guidelines were identified as relevant to digoxin use specifically in the elderly. In an elderly population (aged ≥65 years; n = 7) compared with a younger population (aged <65 years; n = 6), the elderly had a significant increase in digoxin t(1/2) (mean [SD]: oral dosing, 69.6 [13.1] vs 36.8 [4.5] hours; N dosing, 68.8 [12.3] vs 38.2 [3.5] hours; both, P < 0.05) and a decrease in total-body clearance (0.8 [0.2] vs 1.7 [0.2] mL/min/kg; P < 0.05). The use of digoxin in heart failure has been found to reduce the risk of hospitalization (risk ratio = 0.72; 95% CI, 0.66-0.79; P < 0.001). This beneficial effect of digoxin was found to be not significantly different across age groups in those aged >18 years. In terms of atrial fibrillation, the ability of digoxin to control the ventricular rate is believed to be caused by its vagotonic effect on the atrioventricular node. Therefore, digoxin is recommended for ventricular rate control only in patients with heart failure or sedentary lifestyle (ie, low sympathetic tone), or in those who cannot tolerate other rate-control agents. Because the prevalence of heart failure is high among the elderly (15.2 per 1000 population at age 65-74 years, 31.7 per 1000 population at age 75-84 years, and 65.2 per 1000 population at age ≥85 years), many of whom have a relatively sedentary lifestyle, digoxin may be an appropriate agent for ventricular rate control in the elderly. CONCLUSIONS: The elderly population appears to gain comparable benefits as does a younger population from the use of digoxin for heart failure management in terms of symptom improvement and reduction of hospitalization. In atrial fibrillation, digoxin does not control the ventricular rate as efficaciously during exercise and in high adrenergic states as do R-blockers and calcium channel blockers. The elderly have reduced elimination of digoxin, so if digoxin is to be used, the dosing strategy must be conservative and therapeutic monitoring is needed. Further clinical studies are needed to confirm the pharmacokinetic parameters of digoxin in elderly patients with heart failure and/or atrial fibrillation.
Treatment of elderly patients with type 2 diabetes mellitus: a systematic review of the benefits and risks of dipeptidyl peptidase-4 inhibitors.
Schwartz SL
Am J Geriatr Pharmacother · 2010 Oct · PMID 21335294 · Publisher ↗
BACKGROUND: Achievement of glycemic control in elderly patients with type 2 diabetes mellitus (DM) is complicated by many factors. OBJECTIVE: The aim of this article was to systematically review evidence on the effective...
BACKGROUND: Achievement of glycemic control in elderly patients with type 2 diabetes mellitus (DM) is complicated by many factors. OBJECTIVE: The aim of this article was to systematically review evidence on the effectiveness of dipeptidyl peptidase-4 (DPP-4) inhibitors (ie, lowering of glycosylated hemoglobin [HbA(1c)]), the risk of hypoglycemia associated with these agents, and the effects of these agents on body weight in elderly patients with type 2 DM. METHODS: The PubMed and Biosis databases were searched for reports of clinical trials and meeting presentations (eg, abstracts, posters) published in English between January 1, 2000, and October 25, 2009, that included elderly patients with type 2 DM who were treated with sitagliptin, saxagliptin, vildagliptin, alogliptin, BI-1356, DSP-7238, or PF-734200. Pharmacokinetic and pharmacodynamic studies were excluded from the review, as were studies that did not specifically provide quantitative clinical data on glycemic parameters or specifically list patients aged ≥65 years. RESULTS: Eighty-five articles and 5 presentations were identified in the search; of those, 18 articles and 3 presentations were included in the review. These publications described studies of DPP-4 inhibitors administered as monotherapy or in combination with metformin, a thiazolidinedione, glimepiride, glibenclamide, or insulin. Quantitative data indicated that, in these elderly patients (generally defined as ≥65 years of age) with type 2 DM, DPP-4 inhibitors were associated with significant HbA(1c) reductions that ranged from ~0.7% (baseline HbA(1c) = 7.8%; P < 0.001) to 1.2% (baseline HbA(1c) = 8.3%; P < 0.05). Additional studies that did not quantify the number of elderly patients (as would a subanalysis), but did specify that elderly patients were included and that patient age did not influence the results, were incorporated in this review to support the quantitative results. No significant differences were noted in the HbA(1c)-lowering effects of these agents between elderly and younger patients. Less information about the incidence of hypoglycemia or weight gain in elderly patients was reported, but the available results suggested that the risk of hypoglycemia with DPP-4 inhibitors was not significantly different from that with placebo (sitagliptin 50 or 100 mg/d [0%] vs placebo [0%]; saxagliptin 5 mg/d [6.3%] vs placebo [8.0%]; vildagliptin 100 mg/d [2.32 events per patient-year] vs placebo [2.64 events per patient-year]; alogliptin 12.5 mg/d [8.0%] vs placebo [10.5%]) and that these agents were weight neutral (change, ≤0.9 kg). CONCLUSIONS: For elderly patients with type 2 DM, reductions in HbA(1c) after treatment with a DPP-4 inhibitor were not significantly different from those in younger patients. Use of DPP-4 inhibitors in these studies was associated with a low risk of hypoglycemia, and these agents were weight neutral.
Letter to the editors.
Bell JS, Hartikainen S
Am J Geriatr Pharmacother · 2010 Aug · PMID 20869625 · Publisher ↗
Abstract loading — click title to view on PubMed.
Use of antiparkinson medications among elderly Medicare beneficiaries with Parkinson's disease.
Wei YJ, Stuart B, Zuckerman IH
Am J Geriatr Pharmacother · 2010 Aug · PMID 20869624 · Publisher ↗
BACKGROUND: Antiparkinson drugs (APDs) are the mainstay in the management of Parkinson's disease (PD). However, the use of APDs has not been investigated in a nationally representative sample. OBJECTIVES: This study aime...
BACKGROUND: Antiparkinson drugs (APDs) are the mainstay in the management of Parkinson's disease (PD). However, the use of APDs has not been investigated in a nationally representative sample. OBJECTIVES: This study aimed to describe the prevalence and patterns of APD use and to identify determinants of APD use among elderly Medicare beneficiaries with PD. METHODS: Data from the Medicare Current Beneficiary Survey and Medicare claims from 2000 to 2003 were used to identify beneficiaries ≥65 years of age with PD. The APDs included in the study were levodopa, dopamine agonists, monoamine oxidase-B inhibitors, amantadine, anticholinergic agents, and catechol-O-methyltransferase inhibitors. The annual prevalence of APD use was calculated; patterns of APD use were measured by drug class and type of drug regimens (monotherapy or combination therapy). Potential determinants of APD use included sociodemographic characteristics (age, sex, race, education, marital status, and annual income), self-reported health status, residential status (institution or community), prescription drug coverage, disability (functional, physical, and mental), and disease-specific factors (dementia, depression, and other comorbidities). Multivariate logistic regression analyses with generalized estimating equations were used to estimate odds ratios (ORs) of any APD use associated with the determinants. RESULTS: The data revealed 571 beneficiaries with PD (30.1% aged ≥85 years, 55.0% female, 88.3% white), who were observed for a total of 924 person-years. The annual prevalence of APD use was 58.2% (538/924). Levodopa was the most frequently used agent, either as monotherapy or in combination with other APDs (85.5%; 460/538). Multivariate analyses found that patients 65 to 74 years of age (OR = 0.70; 95% CI, 0.49-0.99; P < 0.05) and those ≥85 years of age (OR = 0.57; 95% CI, 0.40-0.81; P < 0.01) were less likely to use APDs than were patients aged 75 to 84 years of age. Patients who had attained a high level of education (more than a high school diploma) were more likely to use APDs than were patients with a low level of education (a high school diploma or less) (OR = 1.51; 95% CI, 1.04-2.19; P < 0.05). In addition, institutionalization (OR = 1.78; 95% CI, 1.17-2.71; P < 0.01), prescription drug coverage (OR = 1.50; 95% CI, 1.15-1.94; P < 0.01), activities of daily living (ADLs) (OR = 1.47; 95% CI, 1.16-1.87; P < 0.01), and depression (OR = 1.25; 95% CI, 1.02-1.53; P < 0.05) were significantly associated with use of APDs. The probability of APD use was lower among those with dementia than among those without dementia (OR = 0.62; 95% CI, 0.48-0.80; P < 0.001). CONCLUSIONS: Almost half of the elderly Medicare beneficiaries with PD in this study did not use any APD between 2000 and 2003. Levodopa was the most frequently used APD, either as monotherapy or in combination with other APDs. The identified determinants of APD use (age, education, prescription drug coverage, ADLs, dementia, depression, and residing in an institution) may be helpful in developing interventions for this population.
Drug therapies for Parkinson's disease: A database analysis of patient compliance and persistence.
Tarrants ML, Denarié MF, Castelli-Haley J … +2 more , Millard J, Zhang D
Am J Geriatr Pharmacother · 2010 Aug · PMID 20869623 · Publisher ↗
BACKGROUND: Evaluating medication adherence in Parkinson's disease (PD) is important to avoid erroneously attributing suboptimal patient outcomes from poor compliance to disease progression or adverse responses to medica...
BACKGROUND: Evaluating medication adherence in Parkinson's disease (PD) is important to avoid erroneously attributing suboptimal patient outcomes from poor compliance to disease progression or adverse responses to medications. OBJECTIVE: This study of patients with PD who were new to PD drug therapy examined patient compliance and persistence, by drug, to provide a comprehensive investigation of medication-taking behavior in PD. METHODS: A retrospective analysis of patients receiving a new PD drug between March 1 and May 31, 2007, was conducted, using the IMS Health longitudinal prescription database, which contains ∼50% of all retail prescriptions and <150 million patients in the United States. Patients were considered to have received a new PD drug if they initiated PD therapy for the first time, added adjunctive PD therapy, or switched one PD drug for another. Patients were categorized as naive to PD therapy (NT) or having prior PD therapy (PT), which included adjunctive use and switches. The PD medications evaluated were rasagiline, levodopa/carbidopa, levodopa/carbidopa/entacapone, the catechol-O-methyltransferase (COMT) inhibitors (entacapone and tolcapone), pramipexole, ropinirole, and selegiline. The study consisted of a 12-month look-back period (during which patients were required to be active in the database), a 3-month selection period (during which patients received their first prescription), and a 12-month observation period. Compliance was measured using the medication possession ratio (MPR; defined as the number of days' supply of medication divided by the number of available days of therapy, from first dispense date in the selection period to last dispense date in the observation period); noncompliance was defined as an MPR ≤80%. Persistence was measured as the duration (days) of uninterrupted therapy. RESULTS: A total of 29,682 patients with PD (19,673 NT, 10,009 PT) received a new PD drug and were analyzed. Of the 19,510 patients included in the compliance analysis, 10,438 (53.5%) had compliance rates >80% and 9072 (46.5%) were noncompliant. For all patients (NT and PT), compliance rates were significantly higher for patients taking rasagiline than for those taking other PD medications (all P < 0.001). For all patients, the highest mean number of persistent days of treatment (147.5) was reported for rasagiline, followed by levodopa/carbidopa/ entacapone (146.9); persistence for both of these drugs was significantly higher than that for the comparator medications (rasagiline vs levodopa/carbidopa, P = 0.002; rasagiline vs pramipexole, P = 0.003; rasagiline vs COMT inhibitors, ropinirole, and selegiline, all P < 0.001; levodopa/carbidopa/entacapone vs levodopa/carbidopa, P = 0.005; levodopa/carbidopa/entacapone vs pramipexole, P = 0.006; levodopa/carbidopa/entacapone vs COMT inhibitors, ropinirole, and selegiline, all P < 0.001). Almost half of the patients (13,103; 44.1%) remained on their PD medication ≥90 days. CONCLUSIONS: This study found a differential compliance and persistence across PD drug therapies. The compliance rate for rasagiline was significantly higher than that for all of the other PD medications. In addition, rasagiline and levodopa/carbidopa/entacapone were associated with significantly higher persistence rates than were the other PD medications.
Tetrabenazine, a monoamine-depleting drug used in the treatment of hyperkinetic movement disorders.
Guay DR
Am J Geriatr Pharmacother · 2010 Aug · PMID 20869622 · Publisher ↗
BACKGROUND: Few drugs are available for the management of hyperkinetic movement disorders such as the dystonias, choreas, dyskinesias, and tics. Those that are available (primarily neuroleptics) are associated with a wid...
BACKGROUND: Few drugs are available for the management of hyperkinetic movement disorders such as the dystonias, choreas, dyskinesias, and tics. Those that are available (primarily neuroleptics) are associated with a wide range of potentially serious adverse effects, including induction of tardive movement disorders. Tetrabenazine (TBZ) is a monoamine-depleting agent initially studied in the 1950s and currently approved by the US Food and Drug Administration for the treatment of chorea in Huntington's disease. OBJECTIVE: This article reviews the chemistry, pharmacology, pharmacokinetics, therapeutic use, tolerability, drug-interaction potential, and dosing and administration of TBZ. METHODS: MEDLINE was searched (1950-February 2010) for English-language articles investigating any aspect of TBZ. Search terms included tetrabenazine, Ro 1-9569, Nitoman, benzoquinolizines, and reserpine. The reference lists of the identified articles were searched for other pertinent publications, particularly those that were not indexed in the 1950s and 1960s. RESULTS: In the search for a chemical compound that was simpler than reserpine while preserving reserpine-like psychotropic activity, TBZ was identified in the 1950s as one member of a large group of benzoquinolizine derivatives. TBZ acts by depletion of the monoamines serotonin, norepinephrine, and dopamine in the central nervous system (CNS). It does this by reversibly inhibiting vesicle monoamine transporter type 2 and thus preventing monoamine uptake into presynaptic neurons. Clinical studies suggest that TBZ may have therapeutic applications in a wide range of hyperkinetic movement disorders. TBZ has been associated with numerous adverse effects, some of them serious and potentially fatal; these include parkinsonism, other extrapyramidal symptoms (particularly akathisia), depression and suicidality, neuroleptic malignant syndrome, and sedation. TBZ is subject to important drug-drug interactions with inhibitors and inducers of cytochrome P450 (CYP) 2D6, reserpine, and lithium. It is one of very few drugs whose dosing is based, in part, on the results of genotyping (in its case, genotyping for CYP2D6 metabolizer status). CONCLUSIONS: TBZ is a complicated drug in terms of its mechanism of action and its activities against the 3 major monoamines in the CNS, making it difficult to predict its efficacy and tolerability in patients with hyperkinetic movement disorders. It is associated with numerous adverse effects and several important drug-drug interactions. Much work remains to be done to determine the therapeutic potential of TBZ in the treatment of hyperkinetic movement disorders.
Management of hallucinations and psychosis in Parkinson's disease.
Eng ML, Welty TE
Am J Geriatr Pharmacother · 2010 Aug · PMID 20869621 · Publisher ↗
BACKGROUND: Hallucinations and psychosis are common in patients with Parkinson's disease (PD), with reported prevalences of up to 48% and 80%, respectively. However, few randomized, double-blind, placebo-controlled trial...
BACKGROUND: Hallucinations and psychosis are common in patients with Parkinson's disease (PD), with reported prevalences of up to 48% and 80%, respectively. However, few randomized, double-blind, placebo-controlled trials evaluating the treatment options have appeared in the literature. The studies that have been published were complicated by lack of agreement on the diagnosis of psychosis in PD, poor completion rates, mixed populations that included dementia, and other issues. Several reviews, guidelines, and consensus statements have sought to establish standards for treating these symptoms of PD. In 2006, the American Academy of Neurology (AAN) published a practice guideline (based on articles published up to 2004) for management of depression, psychosis, and dementia in patients with PD. Since then, a number of relevant studies have been published. OBJECTIVE: The purpose of this article was to review data that have appeared in the literature since publication of the AAN guideline regarding the management of hallucinations and psychosis in PD. METHODS: A literature search of the PubMed, CINAHL, and PsychInfo databases was conducted for human studies published in English from January 2004 to June 2010. All clinical studies were included except case reports and case series. Studies with <20 participants were also excluded. Search terms included psychosis, hallucinosis, hallucination, delusion, Parkinson, atypical antipsychotic, neuroleptic, aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone. RESULTS: Thirteen studies were included in the review: 3 studies of clozapine, 7 studies of quetiapine, 2 head-to-head trials comparing quetiapine and clozapine, and 1 noncomparative trial of clozapine or quetiapine interventions. Most of the studies included participants with a mean age in the early to mid 70s and a mean duration of PD typically >10 years. CONCLUSIONS: Results of the identified studies suggested that patients with PD might benefit from long-term clozapine therapy. Results of the quetiapine studies were conflicting. However, no statistically significant difference in effectiveness was found between quetiapine and clozapine in comparative trials. The significance of the differences in treatment responses between patients with dementia and those without dementia remains unclear, and it was not possible to draw conclusions for or against other atypical antipsychotics because of insufficient evidence. Further studies are needed to address the methodologic issues in the current trials and to assess safety issues in larger cohorts.
Clinical review of treatment options for select nonmotor symptoms of Parkinson's disease.
Wood LD, Neumiller JJ, Setter SM … +1 more , Dobbins EK
Am J Geriatr Pharmacother · 2010 Aug · PMID 20869620 · Publisher ↗
BACKGROUND: Parkinson's disease (PD) is associated with a host of nonmotor symptoms, including psychosis, cognitive impairment, depression, sleep disturbance, swallowing disorders, gastrointestinal symptoms, and autonomi...
BACKGROUND: Parkinson's disease (PD) is associated with a host of nonmotor symptoms, including psychosis, cognitive impairment, depression, sleep disturbance, swallowing disorders, gastrointestinal symptoms, and autonomic dysfunction. The nonmotor symptoms of PD have the potential to be more debilitating than the motor features of the disorder. OBJECTIVE: The aim of this article was to review treatment options for the nonmotor manifestations of PD, including pharmacologic and nonpharmacologic interventions. METHODS: The PubMed and MEDLINE databases were searched for articles published in English between January 1966 and April 2010, using the terms Parkinson's disease, nonmotor, psychosis, hallucination, antipsychotic, cognitive impairment, dementia, depression, sleep disturbance, sleepiness, REM (rapid eye movement) sleep behavior disorder, dysphagia, swallowing disorder, sialorrhea, gastrointestinal, constipation, autonomic dysfunction, orthostatic hypotension, gastroparesis, erectile dysfunction, sexual dysfunction, and urinary dysfunction. Articles were selected for review if they were randomized controlled trials (RCTs), meta-analyses, or evidence-based reviews of treatment of patients with PD, and/or expert opinion regarding the treatment of nonmotor symptoms of PD. RESULTS: A total of 148 articles, including RCTs, meta-analyses, and evidence-based reviews, were included in this review. The treatment of hallucinations or psychosis in PD should include a stepwise reduction in medications for motor symptoms, followed by the use of quetiapine or clozapine. Dementia may be treated with acetylcholinesterase inhibitors. Evidence is lacking concerning the optimal pharmacologic treatment for depression in PD, with expert opinions indicating selective serotonin reuptake inhibitors as the antidepressants of choice. However, the largest study to date found nortriptyline therapy to be efficacious compared with placebo, whereas paroxetine controlled release was not. A variety of sleep disturbances may plague a person with PD, and treatment must be individualized to the patient's specific sleep disturbance pattern and contributing factors. Swallowing disorders may lead to aspiration and pneumonia, and patients with dysphagia should be referred to a speech therapist for further evaluation and treatment. Orthostasis may be treated with nonpharmacologic interventions as well as pharmacologic treatments (eg, fludrocortisone, midodrine, indomethacin). Other autonomic symptoms are managed in a manner similar to that in patients without PD, although careful attention must be aimed at avoiding dopamine-blocking therapies in the treatment of gastrointestinal dysfunction and gastroparesis. CONCLUSIONS: Various pharmacologic and nonpharmacologic strategies are available for the management of the nonmotor symptoms of PD. The challenges associated with nonmotor symptoms must not be forgotten in light of the motor symptoms of PD, and treatment of nonmotor symptoms should be encouraged.
Parkinson's disease and other movement disorders.
Chen JJ
Am J Geriatr Pharmacother · 2010 Aug · PMID 20869619 · Publisher ↗
Abstract loading — click title to view on PubMed.
Probable valproate sodium-associated hypotension.
Ota KS
Am J Geriatr Pharmacother · 2010 Jun · PMID 20624617 · Publisher ↗
BACKGROUND: Valproate sodium, a commonly used antiepileptic drug (AED), is effective for the treatment of status epilepticus and is often used as a second-line agent when other AEDs are contraindicated. Some studies have...
BACKGROUND: Valproate sodium, a commonly used antiepileptic drug (AED), is effective for the treatment of status epilepticus and is often used as a second-line agent when other AEDs are contraindicated. Some studies have reported that infusion of valproate sodium is generally well tolerated, whereas other studies have reported various degrees of hypotension during infusion. The objective of this case report was to call attention to the potential risk of hypotension after intravenous infusion of valproate sodium. CASE SUMMARY: This was the case of a 75-year-old Hispanic man (height, 145 cm; weight, 68 kg) who developed hypotension after receiving an intravenous loading dose of valproate sodium. The patient received the loading dose 12 hours after administration of his last dose of phenytoin (300 mg daily), which had been discontinued secondary to a cutaneous drug reaction. The patient's medical history was significant for seizure disorder, a cerebrovascular accident, and controlled type 2 diabetes mellitus. He was taking glyburide 5 mg daily and aspirin 81 mg daily. At baseline, the patient's blood pressure (measured while seated, at rest, using an upper-extremity cuff) was 135/70 mm Hg. The intravenous loading dose of valproate sodium (20 mg/kg) was administered at a rate of 14 mg/min (total dose, 1280 mg over 90 min). Approximately 2.5 hours after completion of the loading dose, the patient's blood pressure decreased to 107/48 mm Hg. Because our standard operating procedure is to measure blood pressure every 4 hours after the baseline measurement, the patient's hypotension was not detected during the infusion. The next morning (22 hours after completion of the valproate sodium infusion), divalproex sodium 1000 mg orally once daily was initiated as maintenance therapy. The patient's blood pressure reached a nadir of 82/44 mm Hg. The hypotension was treated initially with intravenous fluid hydration with normal saline, but the blood pressure correction was transient using this approach. The patient remained hypotensive for 3 days. The hypotension was ultimately found to be self-limited, and the patient was asymptomatic throughout his hospital stay. The patient's Naranjo adverse drug reaction probability scale score was 6, indicating that the relationship between valproate sodium infusion and hypotension was probable. CONCLUSION: In this case report, infusion of valproate sodium at a rate of 14 mg/min was a probable cause of hypotension in a 75-year-old man.
Prescribing patterns and predictors of high-level polypharmacy in the elderly population: A prospective surveillance study from two teaching hospitals in India.
Harugeri A, Joseph J, Parthasarathi G … +2 more , Ramesh M, Guido S
Am J Geriatr Pharmacother · 2010 Jun · PMID 20624616 · Publisher ↗
BACKGROUND: Polypharmacy has been reported to increase the risks for inappropriate prescribing, adverse drug reactions, geriatric syndromes, and morbidity and mortality in elderly populations in the United States and Eur...
BACKGROUND: Polypharmacy has been reported to increase the risks for inappropriate prescribing, adverse drug reactions, geriatric syndromes, and morbidity and mortality in elderly populations in the United States and Europe. Data on prescribing patterns and polypharmacy in the elderly population in India are limited. OBJECTIVES: The aims of this study were to assess prescribing patterns and to determine the predictors of high-level polypharmacy in the elderly population in 2 tertiary care hospitals in India. METHODS: This prospective surveillance study used medical records from patients aged 60 to 95 years admitted to the medicine wards of the 2 tertiary care hospitals between January 2008 and June 2009. Data on medication prescribing from admission through discharge were reviewed. Diseases were coded using the World Health Organization (WHO) International Classification of Diseases, 10th Revision, and medications were coded using the WHO Anatomical, Therapeutic, and Chemical classification. Concordance of prescribing with the indications in the product labeling as listed in the American Hospital Formulary Services Drug Information 2007 was determined. The prevalences of polypharmacy (5-9 medications) and high-level polypharmacy (>or=10 medications) were determined. Bivariate analysis and multivariate logistic regression analysis were used to determine the influential predictors of high-level polypharmacy during hospital stays. RESULTS: Data from 814 patients were included (493 [60.6%] men, 321 [39.4%] women; median age, 66 years [range, 60-95 years]). Systemic antibacterials were the most commonly prescribed therapeutic class of medications (574 [70.5%]), and pantoprazole was the most commonly prescribed medication (498 [61.2%]). The majority (7/10 [70.0%]) of the most commonly prescribed medications were prescribed as indicated. Medications prescribed "off-label" included pantoprazole (432/498 [86.7%]), ceftriaxone (212/259 [81.9%]), and atorvastatin (109/237 [46.0%]). Polypharmacy and high-level polypharmacy were prescribed in 366 (45.0%) and 370 (45.5%) patients, respectively. On multivariate logistic regression analysis, multiple (>or=3) diagnoses (odds ratio [OR] = 1.55; 95% CI, 1.16-2.08; P = 0.003), angina pectoris (OR = 2.58; 95% CI, 1.50-4.37; P < 0.001), and a length of stay >or=10 days (10-<15 days, OR = 3.14; 95% CI, 2.09-4.71; P < 0.001; and >or=15 days, OR = 5.74; 95% CI, 2.43-13.51; P < 0.001) were found to be predictors of high-level polypharmacy during hospital stays. CONCLUSIONS: The campaign for rational drug use in hospitalized elderly patients in India should promote pantoprazole, ceftriaxone, and atorvastatin prescribing in concordance with their indications. Interventions to reduce the high-level polypharmacy in the elderly during their stays in tertiary care hospitals in India should focus on patients with >/=3 diagnoses, angina pectoris, and/or >or=10 days of hospital stay.
Repeat medication errors in nursing homes: Contributing factors and their association with patient harm.
Crespin DJ, Modi AV, Wei D … +4 more , Williams CE, Greene SB, Pierson S, Hansen RA
Am J Geriatr Pharmacother · 2010 Jun · PMID 20624615 · Publisher ↗
BACKGROUND: Medication errors are highly prevalent in long-term care facilities and are responsible for preventable injury. Repeat medication errors, or identical events occurring multiple times in the same patient, may...
BACKGROUND: Medication errors are highly prevalent in long-term care facilities and are responsible for preventable injury. Repeat medication errors, or identical events occurring multiple times in the same patient, may be particularly preventable. OBJECTIVES: This study assessed the factors that contribute to repeat medication errors and the association between repeat medication errors and patient harm. METHODS: In this cross-sectional analysis, medication error reports submitted by licensed nursing homes to North Carolina's Medication Error Quality Initiative-Individual Error Web-based incident reporting system were analyzed for fiscal years 2006-2008. When reporting errors, the sites were asked whether the event was identically repeated within the same patient. Repeat medication errors were defined as identical events in terms of patient characteristics, drug involved, error type, potential cause, phase of the medication care process, and personnel involved. Repeat errors were compared with nonrepeat errors. Multivariate logistic regression was used to explore whether certain patient or error characteristics were related to a higher likelihood of repeat errors, and a similar analysis was used to explore whether repeat errors were related to patient harm. RESULTS: Of the total 15,037 errors reported by 294 unique nursing homes, 5615 (37.3%) were repeated one or more times. Among the repeat errors, the associated event within each error was repeated a mean (SD) of 10.7 (14.3) times. Wrong dosage (65.1% [3654/5615]) and wrong administration (10.2% [571/5615]) were the most frequent repeated events. In multivariate analysis, repeat errors occurred less frequently among younger residents (aged <75 years) than among older residents (aged >or=75 years) (odds ratio [OR] = 0.85; 95% CI, 0.79-0.93) and among residents able to direct their own care compared with cognitively impaired residents (OR = 0.87; 95% CI, 0.81-0.95). Patient harm was reported in only 1.2% (68/5615) of repeat errors and 0.6% (55/9422) of non-repeat errors. A multivariate analysis of patient harm found that repeat errors were more likely to be harmful than were nonrepeat errors (OR = 2.11; 95% CI, 1.43-3.11). CONCLUSIONS: Repeat medication errors in nursing homes are a common occurrence and have greater odds of being associated with harm than do nonrepeat errors. Future patient-safety research should focus on factors related to repeat errors.
Concerns and beliefs about medicines and inappropriate medications: An Internet-based survey on risk factors for self-reported adverse drug events among older adults.
Shiyanbola OO, Farris KB
Am J Geriatr Pharmacother · 2010 Jun · PMID 20624614 · Publisher ↗
BACKGROUND: Adverse drug events (ADEs), which can be especially problematic in older adults, often can be prevented by detecting potential risk factors. Sociopsychological factors such as concerns and beliefs about medic...
BACKGROUND: Adverse drug events (ADEs), which can be especially problematic in older adults, often can be prevented by detecting potential risk factors. Sociopsychological factors such as concerns and beliefs about medicines (patients' anxieties about the harmful effects of prescribed medications) may also be risk factors related to self-reported ADEs, even when considering clinical variables such as receiving an inappropriate medication. OBJECTIVES: This study was designed to quantify the use of inappropriate medications among older adult outpatients and to determine whether an association exists between the use of inappropriate medications, concerns and beliefs about medicines, and self-reported ADEs. METHODS: This cross-sectional, Internet-based survey of Medicare beneficiaries was conducted in 2007. Harris Interactive, a New York-based marketing research firm, invited participants from their online panel who were >or=65 years of age, residents of the United States, and enrolled in the Medicare health plan to participate in the survey. The updated Beers criteria and a modified version of the Assessing Care of Vulnerable Elders quality indicators were used to determine the appropriateness of medications. Respondents' concerns about their medicines were assessed using items from a validated scale such as "Having to take medicines worries me" and "I sometimes worry about the long-term effects of my medicines." To establish self-reported ADEs, respondents were asked, "Did you see a doctor about any side effects, unwanted reactions, or other problems from medicines you were taking in the past year?" RESULTS: Of the 1024 panelists who responded to the survey, 874 provided all of the information required for analysis. The respondents who were included in the analyses ranged in age from 65 to 94 years; 56.6% were female, 94.4% were white, and 20.3% self-reported an ADE. The frequency of patients receiving either an inappropriate medication or a medication that failed a quality indicator was 45.8%. Stronger concerns and beliefs about medicines (odds ratio [OR] = 1.57; 95% CI, 1.02-2.39; P = 0.04) and having more symptoms (OR = 2.26; 95% CI, 1.22-4.22; P = 0.01) were significantly related to self-reporting of ADEs, whereas receiving an inappropriate medication (OR = 1.03; 95% CI, 0.65-1.64) and the number of medications received (OR = 1.28; 95% CI, 0.52-3.13) were not. CONCLUSIONS: Stronger concerns and beliefs about medicines and having more symptoms were significantly related to self-reporting of ADEs. Receiving an inappropriate medication and the number of medicines received were not significantly related.
Analgesic use among community-dwelling people aged 75 years and older: A population-based interview study.
Pokela N, Bell JS, Lihavainen K … +2 more , Sulkava R, Hartikainen S
Am J Geriatr Pharmacother · 2010 Jun · PMID 20624613 · Publisher ↗
BACKGROUND: Pain is often underrecognized and undertreated among older people. However, older people may be particularly susceptible to adverse drug reactions linked to prescription and nonprescription analgesics. OBJECT...
BACKGROUND: Pain is often underrecognized and undertreated among older people. However, older people may be particularly susceptible to adverse drug reactions linked to prescription and nonprescription analgesics. OBJECTIVES: The aims of this study were to assess the prevalence of analgesic use among a random sample of community-dwelling people aged >or=75 years, and to investigate factors associated with daily and as-needed analgesic use. METHODS: A random sample of people aged >or=75 years was drawn from the population register in Kuopio, Finland, in November 2003. Data on prescription and nonprescription analgesic use were elicited during nurse interviews conducted once for each participant in 2004. Self-reported drug utilization data were verified against medical records. The interview included items pertaining to sociodemographic factors, living conditions, social contacts, health behavior, and state of health. Physical function was assessed using the Instrumental Activities of Daily Living Scale, and the 10-item Barthel Index. Self-rated mobility was assessed by asking whether respondents could walk 400 meters (yes, yes with difficulty but without help, not without help, or no). Cognitive function was assessed using the Mini-Mental State Examination. The presence of depressive symptoms was assessed using the 15-item Geriatric Depression Scale. Respondents' self-rated health was determined using a 5-point scale (very poor, poor, moderate, good, or very good). RESULTS: Of the initial random sample of participants (N = 1000), 700 provided consent to participate and were community dwelling. Among the participants, 318 (45.4%) were users of >or=1 analgesic on a daily or as-needed basis. Only 23.3% of analgesic users took an analgesic on a daily basis. Factors associated with any analgesic use included female sex (odds ratio [OR], 1.78 [95 degrees % CI, 1.17-2.71]), living alone (OR, 1.46 [95 degrees % CI, 1.02-2.11]), poor self-rated health (OR, 2.6 [95% CI, 1.22-3.84]), and use of >or=10 nonanalgesic drugs (OR, 2.21 [95% CI, 1.26-3.87]). Among users of >or=1 oral analgesic, factors associated with opioid use included moderate (OR, 2.46 [95% CI, 1.175.14]) and poor (OR, 2.57 [95% CI, 1.03-6.42]) self-rated health. Opioid use (OR, 0.19 [95% CI, 0.04-0.86]) and daily analgesic use (OR, 0.16 [95% CI, 0.34-0.74]) were inversely associated with depressive symptoms. Pain in the previous month was reported by 71.4% of analgesic users and 26.4% of nonusers of analgesics. CONCLUSIONS: Analgesics were used by approximately 50% of community-dwelling people aged >or=75 years. However, age was not significantly associated with increased use of analgesics in multivariate analysis. The majority of analgesic drugs were used on an as-needed rather than a daily basis (76.7% vs 23.3%, respectively). Factors most significantly associated with analgesic use were female sex, living alone, poor self-rated health, and use of >or=10 nonanalgesic drugs.
A cross-sectional analysis of the prevalence of undertreatment of nonpain symptoms and factors associated with undertreatment in older nursing home hospice/palliative care patients.
Rodriguez KL, Hanlon JT, Perera S … +2 more , Jaffe EJ, Sevick MA
Am J Geriatr Pharmacother · 2010 Jun · PMID 20624612 · Full text
BACKGROUND: Approximately 25% of all US deaths occur in the long-term care setting, and this figure is projected to rise to 40% by the year 2040. Currently, there is limited information on nonpain symptoms and their appr...
BACKGROUND: Approximately 25% of all US deaths occur in the long-term care setting, and this figure is projected to rise to 40% by the year 2040. Currently, there is limited information on nonpain symptoms and their appropriate treatment in this setting at the end of life. OBJECTIVE: This study evaluated the prevalence of undertreatment of nonpain symptoms and factors associated with undertreatment in older nursing home hospice/palliative care patients. METHODS: This study used a cross-sectional sample of older (>or=65 years) hospice/palliative care patients to represent all patients from the 2004 National Nursing Home Survey (NNHS) funded by the Centers for Disease Control and Prevention. Nonpain symptoms were determined from facility staff, who used the medical records to answer questions about the residents. Data on medication use were derived from medication administration records. Undertreatment was defined as the omission of a necessary medication for a specific nonpain symptom and was evaluated as a dichotomous variable (yes = the nonpain symptom was not treated with a medication; no = the nonpain symptom was treated with a medication). Cross-sectional bivariate analyses were conducted using chi(2) and regression coefficient tests to determine factors potentially associated with undertreatment of nonpain symptoms. RESULTS: The cross-sectional sample included 303 older nursing home hospice/palliative care patients from among the 33,413 (weighted) patients from the 2004 NNHS. Overall, most of the patients were white (91.4% [277/303]) and female (71.9% [218/303]), and nearly half were aged >or=85 years (47.9% [145/303]). One or more nonpain symptoms occurred in 82 patients (22.0% weighted). The most common nonpain symptoms (weighted percentages) were constipation/fecal impaction in 35 patients (8.8%), cough in 34 patients (9.2%), nausea/vomiting in 26 patients (7.2%), fever in 11 patients (3.1%), and diarrhea in 9 patients (1.9%). Medication undertreatment of any of the above symptoms was seen in 47 of 82 patients (60.0% weighted), ranging from a low of 26.4% for constipation/ fecal impaction to a high of 88.0% for nausea/vomiting. Undertreated patients had significantly more problems with bed mobility (n [weighted %], 43 [92.3%] vs 21 [67.2%]; P = 0.013), mood (21 [44.7%] vs 7 [19.7%]; P = 0.017), and pressure ulcers (12 [25.7%] vs 2 [6.1%]; P = 0.023) than did treated patients. The undertreated group also had a significantly greater number of secondary diagnoses (weighted mean [SD], 6.5 [0.7] vs 5.2 [0.5]; P = 0.004) but had a shorter length of stay in hospice/ palliative care (120.5 [20.1] vs 219.4 [51.8] days; P < 0.001) or in the nursing home (552.0 [96.5] vs 1285.4 [268.3] days; P = 0.001). CONCLUSIONS: The prevalence of nonpain symptoms was low (22.0% weighted) in older nursing home hospice/palliative care patients. However, medication undertreatment of nonpain symptoms was seen in more than half of these patients. Future quality-improvement initiatives for nursing home hospice/palliative care patients are needed beyond the management of pain symptoms.
A pharmacoepidemiologic study of community-dwelling, disabled older women: Factors associated with medication use.
Crentsil V, Ricks MO, Xue QL … +1 more , Fried LP
Am J Geriatr Pharmacother · 2010 Jun · PMID 20624611 · Publisher ↗
BACKGROUND: Although disabled older adults may be among the subpopulation of adults with the highest risk for adverse drug events (ADEs), reliable data on their use of medications are limited. OBJECTIVES: The aims of thi...
BACKGROUND: Although disabled older adults may be among the subpopulation of adults with the highest risk for adverse drug events (ADEs), reliable data on their use of medications are limited. OBJECTIVES: The aims of this study were to describe the extent and patterns of medication use in community-dwelling, disabled older women, and to identify factors associated with medication use in this population. METHODS: Cross-sectional analyses of baseline data on medication use from the Women's Health and Aging Study I (WHAS I) were performed. WHAS I was an observational study of 1002 community-dwelling women aged >or=65 years who self-reported difficulty in at least 2 of 4 domains of physical functioning (ie, upper-extremity functions, mobility, self-care, and higher functioning tasks needed for independent living in the community). After descriptive analyses of their prescription and over-the-counter (OTC) drugs, associations between participants' characteristics and medication utilization were determined, using generalized linear models. RESULTS: Of the 975 participants, 580 (59.5%) used >or=5 medications and 115 (11.8%) used >or=10 medications (prescriptions and OTCs). The mean number of medications used was 3.9 for prescription drugs and 1.9 for OTC drugs. Cardiovascular drugs and analgesics were the most frequently used prescription and OTC drugs, respectively. Participants with complete outcome and covariate data (n = 803) were included in the multivariate analyses. Cancer was associated with a 13% increase in total medication use (95% CI, 1.00-1.27). Multimorbidity (1.08; 95% CI, 1.02-1.15), frailty (1.13; 95% CI, 1.02-1.26), high Mini-Mental State Examination score (1.03; 95% CI, 1.01-1.05), congestive heart failure (CHF) (1.39; 95% CI, 1.23-1.58), angina (1.27; 95% CI, 1.12-1.44), chronic obstructive pulmonary disease (COPD) (1.20; 95% CI, 1.05-1.37), diabetes mellitus (DM) (1.24; 95% CI, 1.07-1.43), difficulty with shopping for personal items such as medicines and toiletries (1.20; 95% CI, 1.06-1.35), and possession of health insurance (1.21; 95% CI, 1.04-1.40) or a prescription plan (1.16; 95% CI, 1.05-1.29) were independently associated with increased use of prescription drugs. A diagnosis of osteoarthritis of the hands (1.29; 95% CI, 1.121.49) and having a spouse (1.19; 95% CI, 1.01-1.40) were associated with increased use of OTC drugs. Participants with DM (0.78; 95% CI, 0.65-0.94), African Americans (0.70; 95% CI, 0.60-0.82), and those who had difficulty shopping (0.85; 95% CI, 0.72-0.99) used fewer OTCs than did participants without these characteristics. CONCLUSIONS: Most of the disabled older women in this study took >=5 medications at baseline, potentially putting them at high risk for ADEs. Those with multimorbidity, frailty, CHF, angina, DM, COPD, cancer, and difficulty with instrumental activities of daily living are target subpopulations for polypharmacy intervention.
Does influenza vaccination of older adult Medicare beneficiaries lower treatment costs for acute and chronic respiratory disease?
Stuart B, Davidoff A, Lloyd J … +3 more , Shaffer T, Shoemaker JS, Kemner J
Am J Geriatr Pharmacother · 2010 Jun · PMID 20624610 · Full text
BACKGROUND: Influenza accounts for a large proportion of hospitalizations and deaths among older adults, resulting in substantial health care expenses. Influenza vaccinations are effective in reducing respiratory infecti...
BACKGROUND: Influenza accounts for a large proportion of hospitalizations and deaths among older adults, resulting in substantial health care expenses. Influenza vaccinations are effective in reducing respiratory infections in younger populations, but it is less certain whether they reduce costs associated with respiratory infections among older adults. OBJECTIVE: The purpose of this study was to determine whether influenza vaccination of older adult Medicare beneficiaries reduced costs associated with acute and chronic respiratory conditions during 3 recent influenza seasons. METHODS: This study analyzed the relationship between influenza vaccination and costs for respiratory conditions among Medicare beneficiaries >or=55 years of age in influenza seasons (October-May) between 2002 and 2005 using data from the Medicare Current Beneficiary Survey. Two-part multiple regressions of vaccination status were estimated on the probability and cost of treating respiratory conditions in each influenza season controlling for influenza risk factors and other covariates. Various sensitivity tests were conducted by type of service, subgroup analysis for specific population risk segments, propensity score-matched comparisons, and difference equations. RESULTS: The study sample included 13,402 Medicare beneficiaries for the 3 influenza seasons examined. Vaccination rates varied between 67.3% and 74.9% over the 3 influenza seasons. In unadjusted comparisons, no significant difference in the cost of treating respiratory conditions was found between vaccinated and unvaccinated beneficiaries in 2002/2003 (-$104), but vaccinated beneficiaries had significantly higher mean cost differentials in the more recent influenza seasons ($258 in 2003/2004, P = 0.012; $254 in 2004/2005, P = 0.003). Based on 2-part multiple regressions of vaccine status over the 3 seasons combined, costs of respiratory conditions were $142 dollars higher on average for vaccinated beneficiaries (P = 0.014). The base regression models showed no significant cost savings from vaccination in any year. Results of 2 of the 54 sensitivity tests that were conducted indicated significant savings from vaccination (inpatient costs for 2002/2003 and difference in total costs for persons unvaccinated in 2002/2003 but vaccinated in 2003/2004). CONCLUSION: In this study of older adults, no significant cost savings were found with influenza vaccines in the 3 influenza seasons examined (2002-2005) when the outcome was measured in terms of differential spending for acute and chronic respiratory conditions.
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