The American Journal Of Geriatric Pharmacotherapy[JOURNAL]
Sun
200 papers
Interventions to improve suboptimal prescribing in nursing homes: A narrative review.
Marcum ZA, Handler SM, Wright R … +1 more , Hanlon JT
Am J Geriatr Pharmacother · 2010 Jun · PMID 20624609 · Full text
BACKGROUND: Appropriate medication prescribing for nursing home residents remains a challenge. OBJECTIVE: The purpose of this study was to conduct a narrative review of the published literature describing randomized cont...
BACKGROUND: Appropriate medication prescribing for nursing home residents remains a challenge. OBJECTIVE: The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes. METHODS: The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors' files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents. RESULTS: Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention's impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in >or=1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions. CONCLUSIONS: Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature.
Separate episodes of delirium associated with levetiracetam and amiodarone treatment in an elderly woman.
Foley KT, Bugg KS
Am J Geriatr Pharmacother · 2010 Apr · PMID 20439066 · Publisher ↗
BACKGROUND: Delirium related to levetiracetam has not been previously described in the literature and is infrequently associated with amiodarone. OBJECTIVE: The aim of this report was to discuss the possibility that admi...
BACKGROUND: Delirium related to levetiracetam has not been previously described in the literature and is infrequently associated with amiodarone. OBJECTIVE: The aim of this report was to discuss the possibility that administration of levetiracetam and amiodarone may precipitate delirium in some elderly patients. CASE SUMMARY: An 80-year-old white woman with levothyroxine-treated hypothyroidism developed acute confusion and paranoia 5 days after substituting levetiracetam 1000 mg orally twice daily for phenytoin 100 mg orally twice daily to control new, generalized seizures. Before starting levetiracetam treatment, results of the patient's blood and urine tests, brain magnetic resonance imaging, and cerebrospinal fluid examination were within normal limits. Delirium from levetiracetam was suspected. Therefore, the dosage was titrated downward to allow discontinuation of the drug; levetiracetam was replaced with pregabalin 150 mg twice daily. Subsequent improvement in mental status occurred within 14 days after administration of the last dose of levetiracetam. Three months later, the patient developed symptomatic atrial fibrillation, which was treated with cardioversion, followed by oral amiodarone 400 mg twice daily for 10 days and then 200 mg once daily for 3 months. Within 1 to 2 weeks after starting amiodarone, she developed changes in cognition consistent with delirium. Computed tomography of the brain showed no acute changes, and blood test results were within normal limits with the exception of a serum free thyroxine level of 2.06 ng/dL and a suppressed but measurable serum thyroid-stimulating hormone level (0.13 microIU/mL). No improvement was noted after reduction of the dose of levothyroxine from 0.1 mg to 0.075 mg daily. Two weeks after amiodarone was discontinued, her mental status had returned to baseline levels. Based on a score of 6 (probable) for each medication using the Naranjo scale, the 2 episodes of delirium were probably related to levetiracetam and amiodarone. CONCLUSION: This case report describes separate episodes of delirium probably related to treatment with levetiracetam and amiodarone in an elderly patient.
Factors associated with use of calcium and calcium/vitamin D supplements in older Mexican Americans: Results of the Hispanic EPESE study.
Espino DV, Liliana Oakes S, Owings K … +3 more , Markides KS, Wood R, Becho J
Am J Geriatr Pharmacother · 2010 Apr · PMID 20439065 · Full text
BACKGROUND: Current studies indicate that older Mexican Americans take fewer calcium or calcium/vitamin D supplements than do older non-Hispanic whites. Factors associated with calcium supplement use are not completely u...
BACKGROUND: Current studies indicate that older Mexican Americans take fewer calcium or calcium/vitamin D supplements than do older non-Hispanic whites. Factors associated with calcium supplement use are not completely understood in this ethnic group. OBJECTIVE: The purpose of this article was to determine the prevalence of calcium or calcium/vitamin D supplementation and factors associated with their use in older Mexican Americans. METHODS: A cross-sectional survey was conducted in a random sample of older Mexican Americans residing in the southwestern United States who had participated in the Hispanic Established Populations for the Epidemiologic Study of the Elderly. Self-identified Mexican Americans >or=75 years of age were enrolled through household interviews in 2004-2005. Each subject was asked to bring all prescription and nonprescription medications that they had used regularly during the previous 2 weeks to allow the interviewer to record the product names. Dosages were not recorded. Subjects were assigned to 1 of 3 categories based on their use of calcium or calcium/vitamin D supplements during the previous 2 weeks: (1) calcium supplement only, (2) calcium/vitamin D supplement, or (3) vitamin D supplement only. The subjects' sociodemographic and cultural factors, self-reported health and functional status, cognitive status, number of comorbidities, and use of antiosteoporosis medications were recorded. RESULTS: A total of 2069 older Mexican Americans (1272 women, 797 men; mean age, 81.9 years) were enrolled. The overall prevalence of calcium supplement use was 10.6% (weighted). Calcium supplements were used more often by women (odds ratio [OR] = 1.76; 95% CI, 1.17-2.63), subjects with multiple comorbidities (OR = 1.29; 95% CI, 1.10-1.50), those who interviewed in English (OR = 1.59; 95% CI, 1.06-2.40), and those who used antiosteoporosis medications (OR = 3.57; 95% CI, 1.85-6.89). CONCLUSIONS: Use of calcium or calcium/vitamin D supplements was low (<60%) among this group of older Mexican Americans. Men are particularly at risk. More should be done to raise awareness regarding the benefits of calcium supplementation in this ethnic group.
Potentially inappropriate medication use in elderly Japanese patients.
Akazawa M, Imai H, Igarashi A … +1 more , Tsutani K
Am J Geriatr Pharmacother · 2010 Apr · PMID 20439064 · Publisher ↗
BACKGROUND: Modified Beers criteria for elderly Japanese patients were developed in 2008 by consensus among 9 experts to reflect regional clinical practice and available medications in Japan. Since then, many physicians...
BACKGROUND: Modified Beers criteria for elderly Japanese patients were developed in 2008 by consensus among 9 experts to reflect regional clinical practice and available medications in Japan. Since then, many physicians and pharmacists have expressed interest in obtaining more information about the criteria and alternative drug choices. OBJECTIVE: This study examined the incidence, health care utilization, and costs associated with potentially inappropriate medications (PIMs) in elderly patients based on the modified Beers criteria. METHODS: A retrospective, observational cohort study was conducted using health insurance claims data in Japan. The study population included elderly patients aged >or=65 years who had at least 2 pharmacy claims in separate months over a 1-year period (April 2006 through March 2007). Use of the PIMs was identified using the modified criteria, and 1-year incidence rates were calculated for the total study population and for subgroups stratified by age and sex. A logistic regression model was used to examine demographic and clinical characteristics associated with PIMs. Health care utilization rates and costs were also analyzed and compared between patients with and without PIMs using generalized linear models. All models included dummy variables indicating age category, female sex, hospitalization, polypharmacy, index month, and number of Elixhauser comorbidities to adjust for potential confounders. RESULTS: Among 6628 elderly patients, 71.2% (4721/6628) were female and 62.9% (4167/6628) were aged 65 to 74 years; 43.6% (2889/6628) were prescribed at least one PIM. The most commonly used PIMs were histamine-2 blockers (20.5% [1356/6628]), benzodiazepines (11.4% [756/6628]), and anticholinergics and antihistamines (7.9% [526/6628]). No significant differences in incidence rates were observed based on age or sex. Inpatient service use, polypharmacy, and comorbidities of peptic ulcer, depression, and cardiac arrhythmias were significant predictors of PIM use while controlling for other factors. PIM users had significantly higher hospitalization risk (1.68-fold), more outpatient visit days (1.18-fold), and higher medical costs (33% increase) than did nonusers. CONCLUSIONS: In a group of elderly Japanese patients, 43.6% used at least one PIM over a 1-year period in this study. PIM use was associated with greater health care utilization rates and costs.
Racial differences in medication adherence: A cross-sectional study of Medicare enrollees.
Gerber BS, Cho YI, Arozullah AM … +1 more , Lee SY
Am J Geriatr Pharmacother · 2010 Apr · PMID 20439063 · Full text
BACKGROUND: Racial differences in adherence to prescribed medication regimens have been reported among the elderly. It remains unclear, however, whether these differences persist after controlling for confounding variabl...
BACKGROUND: Racial differences in adherence to prescribed medication regimens have been reported among the elderly. It remains unclear, however, whether these differences persist after controlling for confounding variables. OBJECTIVE: The objective of this study was to determine whether racial differences in medication adherence between African American and white seniors persist after adjusting for demographic characteristics, health literacy, depression, and social support. We hypothesized that differences in adherence between the 2 races would be eliminated after adjusting for confounding variables. METHODS: A survey on medication adherence was conducted using face-to-face interviews with Medicare recipients >or=65 years of age living in Chicago. Participants had to have good hearing and vision and be able to speak English to enable them to respond to questions in the survey and sign the informed-consent form. Medication adherence measures included questions about: (1) running out of medications before refilling the prescriptions; (2) following physician instructions on how to take medications; and (3) forgetting to take medications. Individual crude odds ratios (CORs) were calculated for the association between race and medication adherence. Adjusted odds ratios (AORs) were calculated using the following covariates in multivariate logistic regression analyses: race; age; sex; living with a spouse, partner, or significant other; income; Medicaid benefits; prescription drug coverage; having a primary care physician; history of hypertension or diabetes; health status; health literacy; depression; and social support. RESULTS: Six hundred thirty-three eligible cases were identified. Of the 489 patients who responded to the survey, 450 (266 African American [59%; mean age, 78.2 years] and 184 white [41%; mean age, 76.8 years]; predominantly women) were included in the sample. The overall response rate for the survey was 77.3%. African Americans were more likely than whites to report running out of medications before refilling them (COR = 3.01; 95% CI, 1.72-5.28) and not always following physician instructions on how to take medications (COR = 2.64; 95% CI, 1.50-4.64). However, no significant difference between the races was observed in forgetting to take medications (COR = 0.90; 95% CI, 0.61-1.31). In adjusted analyses, race was no longer associated with low adherence due to refilling (AOR = 1.60; 95% CI, 0.74-3.42). However, race remained associated with not following physician instructions on how to take medications after adjusting for confounding variables (AOR = 2.49; 95% CI, 1.07-5.80). CONCLUSION: Elderly African Americans reported that they followed physician instructions on how to take medications less frequently than did elderly whites, even after adjusting for differences in demographic characteristics, health literacy, depression, and social support.
Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients.
Gizzi LA, Slain D, Hare JT … +3 more , Sager R, Briggs F, Palmer CH
Am J Geriatr Pharmacother · 2010 Apr · PMID 20439062 · Publisher ↗
BACKGROUND: Medication history taking is important because clinicians rely on the information that is collected; however, medication histories are often inaccurate and incomplete. The use of a medication at home without...
BACKGROUND: Medication history taking is important because clinicians rely on the information that is collected; however, medication histories are often inaccurate and incomplete. The use of a medication at home without a corresponding disease or condition in the patient's records (ie, "unspecified" medication) warrants investigation of the need for that medication. The process of reconciling medications with current diseases or conditions on hospital admission has not been officially advocated by The Joint Commission, but it could help clinicians better assess the continued need for home medications and possibly decrease the use of polypharmacy. OBJECTIVES: The objectives of this study were to expand on a previous study conducted at our institution by estimating the prevalence of discrepancies between medication histories and reported diseases or conditions in a larger and more diverse patient population, and to determine whether a pharmacist could clarify the reasons for the unspecified medications, thereby enhancing the medication reconciliation process. METHODS: Patients >or=50 years of age who were taking >or=4 home medications were randomly selected within 24 hours of hospital admission. Medical chart information and home medication lists, obtained shortly after admission, were reviewed retrospectively for the selected patients. Patients were excluded if they were admitted directly to an intensive care unit. Only home medications that the patient continued to take after admission were included in the analysis. Therapeutic hospital formulary substitutes (eg, atorvastatin given instead of pravastatin) were considered to be the same medication. Nonprescription medications, "as needed" medications, and vitamins/supplements taken at home were excluded from analysis. If an unspecified medication was found, a pharmacist proceeded through an algorithm designed to clarify the reason for the unspecified medication. In the event of a common off-label (unapproved) use of a drug, the drug was not considered unspecified. RESULTS: Home medication lists were available for 300 patients (154 women, 146 men; mean [SD] age, 69 [10.6] years; >98% white) admitted to a 541-bed university hospital between December 2007 and June 2008; a total of 114 patients (38%) had >or=1 unspecified medication. Of the 200 unspecified medications reported in patient charts, the 2 most frequently reported drug classes were proton pump inhibitors and selective serotonin reuptake inhibitors, used by 21% and 11% of patients, respectively. Patients with unspecified medications received a higher mean number of home medications (9.7 vs 7.6 per patient; odds ratio = 1.18; 95% CI, 1.11-1.28; P < 0.001). Rates of discordance were independent of age, sex, and pathway to admission to the emergency department. Ultimately, the study pharmacist was able to clarify 96% of the unspecified medications by applying the study algorithm. Answers were provided by patients (80%), old clinic or hospital chart notes (12%), or physicians (4%); 4% could not be clarified. CONCLUSIONS: Many of the unspecified medications that were identified in this study have been associated with polypharmacy in the literature. The results of this study suggest that matching home medications with indications for those medications on admission to the hospital enhanced the medication reconciliation process. Direct patient questioning by the pharmacist clarified medication use and contributed to more accurate and complete medication history taking.
Inpatient medication reconciliation at admission and discharge: A retrospective cohort study of age and other risk factors for medication discrepancies.
Unroe KT, Pfeiffenberger T, Riegelhaupt S … +3 more , Jastrzembski J, Lokhnygina Y, Colón-Emeric C
Am J Geriatr Pharmacother · 2010 Apr · PMID 20439061 · Full text
BACKGROUND: Medication discrepancies are unintended differences between medication regimens (ie, between a patient's home regimen and medications prescribed on admission to the hospital). OBJECTIVE: The goal of this stud...
BACKGROUND: Medication discrepancies are unintended differences between medication regimens (ie, between a patient's home regimen and medications prescribed on admission to the hospital). OBJECTIVE: The goal of this study was to describe the incidence, drug classes, and probable importance of hospital admission medication discrepancies and discharge regimen differences, and to determine whether factors such as age and specific hospital services were associated with greater frequency of medication discrepancies and differences. METHODS: This was a retrospective cohort study of a random sample of adult patients admitted to the general medicine, cardiology, or general surgery services of a tertiary care academic teaching hospital between July 1, 2006, and August 31, 2006. A chart review was performed to collect the following information: patient demographic characteristics, comorbid conditions, number of preadmission medications, discrepant medications identified by the hospital's reconciliation process, reasons for the discrepancies, and discharge medications that differed from the home regimen. Potentially high-risk discrepancies and differences were identified by determining if the medications were included on either the Institute for Safe Medication Practices high-alert list or the North Carolina Narrow Therapeutic Index list. Univariate and multivariate logistic regression analyses were used to identify factors associated with medication discrepancies and differences. RESULTS: Of the 205 patients (mean age, 59.9 years; 116 men, 89 women; 60% white) included in the study, 27 did not have any medications recorded on admission. Of the 178 patients who did have medications listed, 41 had >or=1 discrepancy identified by the reconciliation process on admission (23%; 95% CI, 17-29); 19% (95% CI, 11-31) of these medications were considered to be potentially high risk. In the multivariate logistic regression model, age (odds ratio [OR] per 5-year increase = 1.16; 95% CI, 1.01-1.33; P = 0.035), presence of high-risk medications on admission (OR = 76.68; 95% CI, 9.13-643.76; P < 0.001), and general surgery service (OR = 3.31; 95% CI, 1.40-7.87; P < 0.007) were associated with a higher proportion of patients with discrepancies on admission. At discharge, 196 patients (96% [95% CI, 93<98]) had >or=1 medication change from their home regimen, with 1102 total differences for 205 patients. Less than half (44% [95% CI, 37-51]) of these patients were explicitly alerted at discharge to new medications or dose changes; 12% (95% CI, 7-18) were given written instructions to stop taking discontinued home medications. Cardiovascular drugs were the most frequent class involved at both admission (31%) and discharge (27%) in medication discrepancies or differences. CONCLUSIONS: Medication discrepancies on admission and medication differences at discharge were prevalent for adult patients admitted to the general medicine, cardiology, and general surgery services in this academic teaching hospital. Medication reconciliation processes have a high potential to identify clinically important discrepancies for all patients.
Alternative formulations, delivery methods, and administration options for psychotropic medications in elderly patients with behavioral and psychological symptoms of dementia.
Muramatsu RS, Litzinger MH, Fisher E … +1 more , Takeshita J
Am J Geriatr Pharmacother · 2010 Apr · PMID 20439060 · Publisher ↗
OBJECTIVE: The purpose of this paper was to review alternative formulations, delivery methods, and administration options for psychotropic medications in elderly patients with behavioral and psychological symptoms of dem...
OBJECTIVE: The purpose of this paper was to review alternative formulations, delivery methods, and administration options for psychotropic medications in elderly patients with behavioral and psychological symptoms of dementia (BPSD). METHODS: A MEDLINE search was conducted initially in December 2008 and was updated in September 2009, including the search terms pharmacologic treatment and dementia, behavioral and psychological symptoms of dementia, alternative psychotropic medication formulations, alternative dosing methods of medication, drug delivery options, antidepressants and dementia, anxiolytics and dementia, antipsychotics and dementia, mood stabilizers and dementia, cognitive enhancers and dementia, medications and enteral feeding tubes, and hiding medication. Studies were limited to English-language articles dated from 1950 to 2009. Additional relevant articles were obtained by reviewing the references in the initial articles. Drug Facts and Comparisons 4.0 Online, Lexi-Comp Online, and Lexi-Drugs Online were used to obtain additional information. Targeted patients were elderly individuals with BPSD who were considered difficult to treat because they were unable to swallow, were refusing medications, or were not able to eat or drink per physician order. RESULTS: In addition to the standard capsule or tablet given orally, a variety of formulations and delivery methods for psychotropic medications are available. Options include short- and long-acting intramuscular, intravenous, liquid, orally disintegrating, transdermal patch, sublingual, and rectal forms. Additionally, all formulations can be further altered in substance, delivery, or both. For example, tablets may be crushed and capsules opened; this changes their formulation and allows the option of mixing with food or liquids to be taken by mouth or through a tube. Caution must be used, however; in certain cases, alteration of the original form or the intended delivery method is contraindicated. In addition, many alternative administration options are not formally approved for use in the manner in which they are commonly applied and are therefore used with little or no information on tolerability and effectiveness. Ethical and legal issues include patient consent and off-label use. CONCLUSIONS: Overall, few studies have examined the use and efficacy of alternative psychotropic formulations and delivery methods in elderly patients with BPSD, and none have specifically addressed drug-alteration and alternative-administration issues. There is no evidence to compare alternative delivery forms (eg, tablet or capsule) of a given medication in terms of efficacy or tolerability. Still, alternative methods may be the only option for treatment of some patients. Practitioners must be familiar with the range of formulations and delivery options available so that they can optimize their patients' medication regimens. More data are needed on the use of alternative formulations, delivery methods, and administration options and their limitations in this population.
Medication misadventures in the elderly: a year in review.
Marcum ZA, Handler SM, Boyce R … +2 more , Gellad W, Hanlon JT
Am J Geriatr Pharmacother · 2010 Feb · PMID 20226395 · Full text
OBJECTIVE: This paper reviews recent articles examining medication misadventures that can be defined as medication errors and adverse drug events in the elderly. METHODS: MEDLINE and International Pharmaceutical Abstract...
OBJECTIVE: This paper reviews recent articles examining medication misadventures that can be defined as medication errors and adverse drug events in the elderly. METHODS: MEDLINE and International Pharmaceutical Abstracts were searched for articles published in English in 2009 using a combination of the terms medication errors, medication adherence, suboptimal prescribing, monitoring, adverse drug events, adverse drug withdrawal events, therapeutic failure, 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. Those studies that described unique approaches to evaluating medication misadventures in the elderly were included in the review. RESULTS: The search identified 5 unique studies relating to medication misadventures in the elderly. A cross-sectional study found that a new 8-item paper-and-pencil adherence survey-the Morisky Medication Adherence Scale-was significantly associated with antihypertensive drug pharmacy refill adherence (P < 0.05). A cross-sectional study of medication discrepancies that occurred during transition from the hospital to a nursing home found discrepancies in almost 75% of patients. A randomized controlled trial of a computer-generated decision support intervention to reduce potentially inappropriate prescribing in an emergency department found that the intervention was associated with a significant reduction in prescriptions for such medications (P = 0.02). One study found that patients who were taking digoxin and had been hospitalized during the previous 2 months were at significantly increased risk for additional hospitalizations due to digoxin toxicity. A survey study of Medicare beneficiaries found that use of multiple types of inappropriate medications was a risk factor for self-reported adverse drug events, independent of the number of medications taken. CONCLUSION: Data from these recently published studies could be used to guide the development and evaluation of quality improvement, research, or clinical practice initiatives.
Ranolazine-related dyspnea on exertion.
Goswami R, Van De Car D, Schmader KE … +2 more , Bashore TM, Sketch MH
Am J Geriatr Pharmacother · 2010 Feb · PMID 20226394 · Publisher ↗
BACKGROUND: Ranolazine is increasingly being prescribed for the treatment of chronic stable angina. This report describes an adverse effect that may be related to ranolazine. CASE SUMMARY: A 77-year-old white man with ch...
BACKGROUND: Ranolazine is increasingly being prescribed for the treatment of chronic stable angina. This report describes an adverse effect that may be related to ranolazine. CASE SUMMARY: A 77-year-old white man with chronic renal insufficiency was evaluated for moderate dyspnea on exertion (DOE). Cardiac and pulmonary workup revealed nonobstructive coronary artery disease and mild obstructive lung disease. The patient had been taking ranolazine 500 mg daily for possible angina for the past 2 months. Given the temporal association of his symptoms with drug initiation, ranolazine was discontinued during the hospitalization. One month after discontinuing ranolazine, the patient's DOE had completely resolved; the only intervention had been discontinuation of ranolazine. The patient's Naranjo algorithm score was 3, indicating a possible adverse drug reaction. CONCLUSIONS: No previous cases of ranolazine-related DOE requiring drug cessation have been published. Ranolazine may be associated with DOE in this elderly man.
Polypharmacy in nursing home residents in the United States: results of the 2004 National Nursing Home Survey.
Dwyer LL, Han B, Woodwell DA … +1 more , Rechtsteiner EA
Am J Geriatr Pharmacother · 2010 Feb · PMID 20226393 · Publisher ↗
BACKGROUND: Despite the need for and benefits of medications, polypharmacy (defined here as concurrent use of > or =9 medications) in nursing home residents is a concern. As the number of medications taken increases, so...
BACKGROUND: Despite the need for and benefits of medications, polypharmacy (defined here as concurrent use of > or =9 medications) in nursing home residents is a concern. As the number of medications taken increases, so does the risk for adverse events. Monitoring polypharmacy in this population is important and can improve the quality of nursing home care. OBJECTIVES: The aims of this article were to estimate the use of polypharmacy in residents of nursing homes in the United States, to examine the associations between select resident and facility characteristics and polypharmacy, and to determine the leading therapeutic subclasses included in the polypharmacy received by these nursing home residents. METHODS: This was a retrospective, cross-sectional study of a nationally representative sample of US nursing home residents in 2004; the outcome was use of polypharmacy. The 2004 National Nursing Home Survey was used to collect medication data and other resident and facility information. Resident characteristics included age, sex, race, primary payment source, number of comorbidities, number of activities of daily living (ADLs) for which the resident required assistance, and length of stay (LOS) since admission. Facility characteristics included ownership and size (number of beds). RESULTS: Of 13,507 nursing home residents who received care, 13,403 had valid responses for all 9 independent variables in the analyses. The prevalence of polypharmacy among nursing home residents in 2004 was approximately 40%. A multiple regression model controlling for resident and facility factors revealed that the odds of receiving polypharmacy were higher for residents who were female (odds ratio [OR] = 1.10; 95% CI, 1.00-1.20), were white, had Medicaid as a primary payer, had >3 comorbidities (OR = 1.57-5.18; 95% CI, 1.36-6.15), needed assistance with < or =4 ADLs, had an LOS since admission of 3 to <6 months (OR = 1.25; 95% CI, 1.04-1.50), and received care in a small, not- for-profit facility (data not shown for reference levels [OR = 1.00]). The most frequently reported medications for residents who received polypharmacy included gastrointestinal agents (laxatives, 47.5%; agents for acid/peptic disorders, 43.3%), drugs that affect the central nervous system (antidepressants, 46.3%; antipsychotics or antimanics, 25.9%), and pain relievers (nonnarcotic analgesics, 43.6%; antipyretics, 41.2%; antiarthritics, 31.2%). CONCLUSIONS: Despite awareness of polypharmacy and its potential consequences in older patients, results of our analysis suggest that polypharmacy remains widespread in US nursing homes. Although complex medication regimens are often necessary for nursing home residents, monitoring polypharmacy and its consequences may improve the quality of nursing home care and reduce unnecessary health care spending related to adverse events.
Community-acquired pneumonia in the elderly.
Fung HB, Monteagudo-Chu MO
Am J Geriatr Pharmacother · 2010 Feb · PMID 20226392 · Publisher ↗
BACKGROUND: Community-acquired pneumonia (CAP) is a frequent cause of hospitalization and death among the elderly. OBJECTIVE: This article reviews information on CAP among the elderly, including age-related changes, pred...
BACKGROUND: Community-acquired pneumonia (CAP) is a frequent cause of hospitalization and death among the elderly. OBJECTIVE: This article reviews information on CAP among the elderly, including age-related changes, predisposing risk factors, causes, treatment strategies, and prevention. METHODS: Searches of MEDLINE (January 1990-November 2009), International Pharmaceutical Abstracts (January 1990-November 2009), and Google Scholar were conducted using the terms community-acquired pneumonia, pneumonia, treatment guidelines, and elderly. Additional publications were found by searching the reference lists of the identified articles. Studies that reported diagnostic criteria as well as the treatment outcomes achieved in adult patients with CAP were selected for this review. RESULTS: Three practice guidelines, 5 reviews, and 43 studies on CAP in the elderly were identified in the literature search. Based on those publications, risk factors that predispose the elderly to pneumonia include comorbid conditions, poor functional and nutritional status, consumption of alcohol, and smoking. The clinical presentation of pneumonia in the elderly (>/=65 years of age) may be subtle, lacking the typical acute symptoms (fever, cough, dyspnea, and purulent sputum) observed in younger adults. Pneumonia should be suspected in all elderly patients who have fever, altered mental status, or a sudden decline in functional status, with or without lower respiratory tract symptoms such as cough, purulent sputum, and dyspnea. Treatment of CAP in the elderly should be guided by the latest recommendations of the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS), along with consideration of local rates and patterns of antimicrobial resistance, as well as individual patient risk factors for acquiring less common or more resistant pathogens. Recommended empiric antimicrobial regimens generally consist of either a beta-lactam plus a macrolide or a respiratory fluoroquinolone alone. Adherence to the IDSA/ATS guidelines has been found to improve in-hospital mortality (adherence vs nonadherence, 8%; 95% CI, 7%-10% vs 17%; 95% CI, 14%-20%; P< 0.01), length of hospital stay (8 days; interquartile range [IQR], 5-15 vs 10 days; IQR, 6-24 days, respectively; P < 0.01), and time to clinical stability in elderly patients with CAP (percentage of stable patients by day 7, 71%; 95% CI, 68%-74% vs 57%; 95% CI, 53%-61%, respectively; P < 0.01). All elderly patients should be vaccinated against pneumococcal disease and influenza based on recommendations from the Centers for Disease Control and Prevention. Lifestyle modifications and nutritional support are also important elements in the prevention of pneumonia in the elderly. CONCLUSION: Adherence to established guidelines, along with customization of antimicrobial therapy based on local rates and patterns of resistance and patient-specific risk factors, likely will improve the treatment outcome of elderly patients with CAP.
A review of the effect of anticonvulsant medications on bone mineral density and fracture risk.
Lee RH, Lyles KW, Colón-Emeric C
Am J Geriatr Pharmacother · 2010 Feb · PMID 20226391 · Full text
BACKGROUND: Osteoporosis and seizure disorders are common diagnoses in older adults and often occur concomitantly. OBJECTIVE: The goal of this review was to discuss the current hypothesis for the pathogenesis of anticonv...
BACKGROUND: Osteoporosis and seizure disorders are common diagnoses in older adults and often occur concomitantly. OBJECTIVE: The goal of this review was to discuss the current hypothesis for the pathogenesis of anticonvulsant-induced bone density loss and the evidence regarding the risk for osteoporosis and fractures in older individuals. METHODS: A review of the literature was performed, searching in MEDLINE and CINAHL for articles published between 1990 and October 2009 with the following search terms: anticonvulsant OR antiepileptic; AND osteoporosis OR bone density OR fracture OR absorptiometry, photon. Studies within the pediatric population, cross-sectional studies, and studies whose results were published in a language other than English were excluded. RESULTS: A search of the published literature yielded >300 results, of which 24 met the inclusion and exclusion criteria and were included in this review. Hepatic enzyme induction by certain anticonvulsant medications appears to contribute to increased metabolism of 25-hydroxyvitamin D to inactive metabolites, which results in metabolic bone disease. There is increasing evidence that anticonvulsant use is associated with a higher risk of osteoporosis and clinical fractures, especially among older agents such as phenobarbital, carbamazepine, phenytoin, and valproate. Several observational studies suggest a class effect among anticonvulsant agents, associated with clinically significant reductions in bone mineral density and fracture risk. The use of anticonvulsant medications increases the odds of fracture by 1.2 to 2.4 times. However, only 2 large-scale observational studies have specifically examined the risk among those aged >65 years. This review also identified a randomized controlled trial whose results suggest that supplementation with high-dose vitamin D may be associated with increased bone mineral density in patients taking anticonvulsant medications. However, no randomized controlled trials investigating therapeutic agents to prevent fracture in this population were identified. Consequently, there are no formal practice guidelines for the monitoring, prevention, and management of bone disease among those taking anticonvulsants. CONCLUSIONS: Observational studies suggest an association between use of anticonvulsant medications, reduced bone mineral density, and increased fracture risk. Randomized clinical trials are needed to guide the management of bone disease among those who use anticonvulsants.
Extraskeletal effects of vitamin D in older adults: cardiovascular disease, mortality, mood, and cognition.
Barnard K, Colón-Emeric C
Am J Geriatr Pharmacother · 2010 Feb · PMID 20226390 · Publisher ↗
BACKGROUND: Vitamin D insufficiency is prevalent among older adults and may be associated with higher risk for cardiovascular (CV) disease, mortality, depression, and cognitive deficits. OBJECTIVE: The aim of this articl...
BACKGROUND: Vitamin D insufficiency is prevalent among older adults and may be associated with higher risk for cardiovascular (CV) disease, mortality, depression, and cognitive deficits. OBJECTIVE: The aim of this article was to review published observational and experimental studies that explored the association between vitamin D insufficiency and CV disease, mortality, mood, and cognition with an emphasis on older adults. METHODS: PubMed and Web of Science databases were searched for English-language articles from January 1966 through June 2009 relating to vitamin D, using the following MeSH terms: aged, vitamin D deficiency, physiopathology, drug therapy, cardiovascular diseases, blood pressure, mortality, delirium, dementia, cognitive disorders, depression, depressive disorder, seasonal affective disorder, mental disorders, and vitamin D/therapeutic use. Publications had to include patients > or =65 years of age who had > or =1 recorded measurement of 25-hydroxyvitamin D (25[OH]D) or were receiving vitamin D supplementation. All case-control, cohort, and randomized studies were reviewed. RESULTS: Forty-two case-control, cohort, and randomized trials were identified and included in the review. Based on these publications, the prevalence of vitamin D insufficiency (25[OH]D concentration <30 ng/mL) in communitydwelling older adults (> or =65 years of age) ranged from 40% to 100%. Epidemiologic data and several small randomized trials found a potential association between vitamin D deficiency (25[OH]D concentration <10 ng/mL) and CV disease, including hypertension and ischemic heart disease. Although subgroup analyses of data from the Women's Health Initiative Randomized Trial (the largest randomized, placebo-controlled trial of vitamin D plus calcium therapy) did not find reductions in blood pressure, myocardial infarction, or CV disease-related deaths, intervention contamination limited the findings. Observational studies and a meta-analysis of randomized controlled trials found a mortality benefit associated with higher serum 25(OH)D concentrations or vitamin D(2) or D(3) supplementation (mean dose, 528 IU/d). Observational and small randomized trials found a potential benefit of sunlight or vitamin D on symptoms of depression and cognition, but the findings were limited by methodologic problems. CONCLUSIONS: Vitamin D insufficiency appears to be highly prevalent among older adults. Evidence from epidemiologic studies and small clinical trials suggests an association between 25(OH)D concentrations and systolic blood pressure, risk for CV disease-related deaths, symptoms of depression, cognitive deficits, and mortality. The Women's Health Initiative Randomized Trial did not find a benefit of vitamin D supplementation on blood pressure, myocardial infarction, or mortality in postmenopausal women.
Perspective: is pharmacy ready for the baby boomers?
Hanlon JT
Am J Geriatr Pharmacother · 2010 Feb · PMID 20226389 · Publisher ↗
Abstract loading — click title to view on PubMed.
Self-reported use of natural health products: a cross-sectional telephone survey in older Ontarians.
Levine MA, Xu S, Gaebel K … +5 more , Brazier N, Bédard M, Brazil K, Lohfeld L, MacLeod SM
Am J Geriatr Pharmacother · 2009 Dec · PMID 20129259 · Publisher ↗
BACKGROUND: The self-reported use of natural health products (NHPs) (herbal products and vitamin and mineral supplements) has increased over the past decade in Canada. Because the elderly population might have comorbidit...
BACKGROUND: The self-reported use of natural health products (NHPs) (herbal products and vitamin and mineral supplements) has increased over the past decade in Canada. Because the elderly population might have comorbidities and concurrently administered medications, there is a need to explore the perceptions and behaviors associated with NHPs in this age group. OBJECTIVE: The goal of this study was to assess the use of NHPs in a cohort of older Canadian residents and the characteristics, perceptions, and behaviors associated with NHP use. METHODS: Survey participants aged > or = 60 years were randomly selected from telephone listings in the area of greater Hamilton, Ontario, Canada. Data were collected using a standardized computer-assisted telephone interview system. Self-reported data covering 7 domains were collected: (1) demographics; (2) self-reported 12-month NHP use; (3) reasons for NHP use; (4) self-reported 12-month prescription medication use; (5) expenditures on NHPs; (6) patient-reported adverse events and drug-NHP interactions; and (7) perceptions of physicians' attitudes regarding NHPs. Descriptive statistics were used to compare the characteristics of NHP users with those of nonusers and to assess the characteristics of NHP users across these 7 domains. Multivariate regression analysis was conducted to determine the demographic variables that might be associated with NHP user status. RESULTS: Of 2528 persons identified as age > or = 60 years, 1206 (48%) completed the telephone interview. Six hundred sixteen of these respondents (51%) reported the use of > or = 1 NHP during the previous 12 months. On the initial univariate analysis, younger age and higher income were significantly associated with reporting NHP use (mean age, users vs nonusers, 71.1 vs 72.7 years, respectively; 95% CI, 1.02-1.06; P < 0.001; income more than Can $26,000 was 28% and 22% in users and nonusers, respectively; P = 0.028). One hundred seventy of 616 users (28%) used an NHP to treat the same condition for which they were concurrently receiving a prescription medication, and 43 (25%) had not informed their physicians about their NHP use. Patients' characteristics such as sex, education, smoking status, and self-reported health status did not differ significantly between users and nonusers. In individuals who regularly spent money to purchase NHPs (n = 394), the mean cost was $20.38/mo. NHP expenditure was not significantly associated with age, sex, or income. CONCLUSION: Based on these findings, a substantial proportion of those Ontarians aged > or = 60 years reported NHP use, and there is a need for greater communication with physicians to avoid potential drug-NHP interactions.
Impact of solifenacin on quality of life, medical care use, work productivity, and health utility in the elderly: an exploratory subgroup analysis.
Zinner N, Noe L, Rasouliyan L … +3 more , Marshall T, Runken MC, Seifeldin R
Am J Geriatr Pharmacother · 2009 Dec · PMID 20129258 · Publisher ↗
BACKGROUND: Overactive bladder (OAB) is a common problem among the elderly and a financial burden to society. The prevalence of OAB increases with age and affects > or = 25% of people aged > or = 65 years. OBJECTIVE: The...
BACKGROUND: Overactive bladder (OAB) is a common problem among the elderly and a financial burden to society. The prevalence of OAB increases with age and affects > or = 25% of people aged > or = 65 years. OBJECTIVE: The goal of this exploratory subgroup analysis of the VESIcare Efficacy and Research Study US (VERSUS) was to assess changes in health-related quality of life (HRQoL), medical care resource utilization, work and activity impairment, and health utility among elderly patients with OAB who continued to have urgency symptoms with tolterodine and were willing to try solifenacin. METHODS: This was a 12-week, multicenter, prospective, open-label, noncomparative, flexible-dosing study designed to assess the efficacy and tolerability of solifenacin. Patients who received tolterodine 4 mg/d for > or = 4 weeks but continued to experience urgency symptoms (> or = 3 urgency episodes/24 hours) were enrolled. This exploratory analysis describes results from 2 elderly cohorts (patients 65 to 74 years and > or = 75 years of age). After a washout period of > or = 14 days, patients began treatment with solifenacin 5 mg/d with dosing adjustments allowed at week 4 (to 10 mg/d) and at week 8 (back to 5 mg/d for patients whose dose was increased to 10 mg/d at week 4). Outcomes were assessed using the OAB-q (a questionnaire specific to OAB and HRQoL), the Work Productivity and Activity Impairment-Specific Health Problem index, the Medical Care Use Index, and the Health Utilities Index Mark 2 and Mark 3 (HUI2/3), administered at the prewashout and week-12 visits. RESULTS: The subgroup analysis included 108 patients 65 to 74 years of age and 86 patients > or = 75 years of age. Patients in both age groups experienced significant improvement in HRQoL (P < 0.001), as well as significant reductions in nonprotocol-related office visits (P < 0.001) and activity impairment (P < 0.025). A significant reduction in the use of pads/diapers was reported for patients 65 to 74 years of age (P < 0.018), and patients in this age group who were working reported significantly less impairment related to OAB while working during solifenacin treatment than during tolterodine treatment (P < 0.042). No significant differences in HUI2/3 scores were observed in either of the elderly subgroups. CONCLUSIONS: Overall, solifenacin was found to improve symptom bother, HRQoL, work productivity, activity participation, and reduced medical care resource utilization in these elderly subjects with OAB who continued to have urgency symptoms with tolterodine and were willing to try solifenacin. This was an exploratory subgroup analysis of an open-label, noncomparative study; further research is needed to confirm these results.
Methodology of a pilot study to improve the quality of medication use in older adults: Enhancing Quality in Psychiatry Using Pharmacists (EQUIPP).
Roth MT, Watson LC, Esserman DA … +4 more , Ivey JL, Hansen R, Lewis CL, Weinberger M
Am J Geriatr Pharmacother · 2009 Dec · PMID 20129257 · Publisher ↗
BACKGROUND: Medication-related problems are prevalent in older adults, contributing to increased harm and health care costs and negatively impacting quality of care. Older adults with psychiatric disease are at an increa...
BACKGROUND: Medication-related problems are prevalent in older adults, contributing to increased harm and health care costs and negatively impacting quality of care. Older adults with psychiatric disease are at an increased risk because of their underlying disease and types of medications prescribed. Efforts to improve the quality of medication use often focus on select medication-related problems, select diagnoses, or predefined quality indicators; however, such an approach fails to consider the potential for multiple coexisting problems within individuals. OBJECTIVE: A pilot study was conducted to test the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease. This article describes the methodology of the study and details of the intervention, and presents baseline characteristics of the study population. METHODS: English-speaking psychiatry outpatients aged > or = 65 years taking > or = 2 drugs that are active in the central nervous system were enrolled into a medication management program, in which medication management was provided by a clinical pharmacist for 6 months. Patients were evaluated at baseline, 3 months, and 6 months. Data were collected on the patients' demographic characteristics, health and medications, health literacy, functional status, symptoms of depression, health services utilization, quality of medication use, adherence, and patient satisfaction with the program. RESULTS: One hundred seventy-three older adults were assessed for inclusion; 146 were not eligible, not reachable, or not interested in participating. Twenty-seven older adults were enrolled in the study, all but one of whom completed the 3- and 6-month visits. The mean (SD) age of the 27 participants was 74.7 (8.1) years; 63% were female, 74% were white, and 70% had no cognitive impairment. CONCLUSIONS: This pilot study tested the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease. Findings from this study, which will be reported at a later date, will help to refine the program and subsequent testing, with the overall goal of improving the quality of medication use and health outcomes in older adults.
National utilization of transdermal fentanyl among community-dwelling older people in Finland.
Bell JS, Klaukka T, Ahonen J … +1 more , Hartikainen S
Am J Geriatr Pharmacother · 2009 Dec · PMID 20129256 · Publisher ↗
BACKGROUND: The use of opioids has increased rapidly in Europe and North America, and older people may be susceptible to opioid-related adverse drug events. The Finnish National Agency for Medicines has recommended that...
BACKGROUND: The use of opioids has increased rapidly in Europe and North America, and older people may be susceptible to opioid-related adverse drug events. The Finnish National Agency for Medicines has recommended that oral opioids be considered the first-line treatment when a strong opioid is required for severe pain. OBJECTIVE: The objective of this study was to investigate and describe the age-, indication-, sex-, and geographic-specific utilization of transdermal fentanyl among older people residing in noninstitutional settings in Finland. METHODS: Reimbursement data for fentanyl, morphine, oxycodone, and hydromorphone were extracted from the Finnish National Prescription Register for 2008. Age-specific population data were used to calculate the annual prevalence of opioid use for malignant and nonmalignant pain for patients aged < or = 64, 65 to 69, 70 to 74, 75 to 79, 80 to 84, 85 to 89, 90 to 94, 95 to 99, and >99 years. The annual prevalence of transdermal fentanyl use was also calculated separately for each of the 21 hospital districts in Finland. RESULTS: Reimbursement for transdermal fentanyl was paid to 2746 people for malignant pain and 6223 people for nonmalignant pain. The annual prevalence of transdermal fentanyl use for nonmalignant pain was lowest among men aged < or = 64 years (2.2 users/10,000 men) and highest among women >99 years (539.2 users/10,000 women). The annual prevalence of transdermal fentanyl use was >47 times higher than that of morphine for nonmalignant pain among people aged 85 to 89 years and >97 times higher than that of morphine among people aged 90 to 94 years. A greater than 4-fold variation in the annual prevalence of transdermal fentanyl use was reported among the 21 hospital districts in Finland (range, 9.5-40.6/10,000 inhabitants). CONCLUSIONS: The prevalence of transdermal fentanyl use was higher than that of morphine, oxycodone, and hydromorphone among people aged > or = 80 years residing in noninstitutional settings in Finland. The variation in use between hospital districts suggests that organizational culture may have a strong impact on prescribing practices. Our data highlight the need for further education regarding the appropriate use of opioids among older people.
Outcomes of irinotecan-based chemotherapy regimens in elderly Medicare patients with metastatic colorectal cancer.
Obeidat NA, Pradel FG, Zuckerman IH … +2 more , DeLisle S, Mullins CD
Am J Geriatr Pharmacother · 2009 Dec · PMID 20129255 · Publisher ↗
BACKGROUND: Several population-based studies have confirmed the benefits of adjuvant chemotherapy with 5-fluorouracil/leucovorin for treatment of colorectal cancer. Few population-based studies have evaluated other chemo...
BACKGROUND: Several population-based studies have confirmed the benefits of adjuvant chemotherapy with 5-fluorouracil/leucovorin for treatment of colorectal cancer. Few population-based studies have evaluated other chemotherapies that are now available for colorectal cancer management. OBJECTIVE: This study primarily sought to evaluate the survival benefit of first-line irinotecan use in a group of Medicare patients with stage IV (metastatic) colorectal cancer. METHODS: Data on chemotherapy users with a diagnosis of colorectal cancer reported between 1998 and 2002 were obtained from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Irinotecan, marketed in 1997, was one of the newer chemotherapy agents in the available data. Chemotherapy episodes, defined as periods of continuous chemotherapy treatment with no gaps >90 days between successive claims, were identified. The first chemotherapy episode after diagnosis was used to identify lines of treatment: patients may have initiated irinotecan therapy within 2 months (first-line), used irinotecan later in the first episode (second-line), or not used irinotecan at all. Descriptive statistics were generated and a multivariable Cox proportional hazards model was used to determine the survival benefit of irinotecan. Secondary analyses explored the survival benefit in specific patient subgroups. The impact of irinotecan use on health care utilization also was assessed. RESULTS: Of 3327 chemotherapy users (mean/median age, 75 years), 842 (25.3%) initiated chemotherapy using irinotecan. No overall survival benefit for irinotecan was observed in the primary analysis comparing irinotecan initiators with all other chemotherapy users (including those who used irinotecan subsequently). Covariates that were negatively associated with survival included older age, presence of >1 comorbidity, a high tumor grade, lymph node involvement, and a primary tumor site in the colon. Surgery was positively associated with a lower hazard of death. In subgroup analyses that excluded subsequent irinotecan users, a survival benefit for irinotecan was observed but diminished over time. Irinotecan users had higher rates of hospitalizations possibly due to chemotherapy-related adverse effects. This retrospective claims study had limitations such as a lack of information on patient performance status, dosing, and the types of regimens used; hence, certain assumptions had to be made and selection bias may have been involved. CONCLUSIONS: The definitive survival advantage of irinotecan observed in clinical trials was not reproducible in this population of elderly Medicare patients. The results emphasize the need for expansion of trials to include a more diverse patient group as well as continued evaluation of more recent chemotherapies in real-world settings.
About
- Frequency
- Sun
- Papers found
- 200
- RSS feed
- Subscribe