The clinical implications of ageing for rational drug therapy

The impact of drug interactions and polypharmacy on antimicrobial therapy in the elderly

Infectious diseases are more prevalent in older people than in younger adults, and represent a major healthcare issue in older populations. Indeed, infections in the elderly are often associated with higher morbidity and mortality, and may present atypically. Additionally, older patients are generally treated with polypharmacy regimens, which increase the likelihood of drug-drug interactions when the prescription of an antimicrobial agent is needed. A progressive impairment in the functional reserve of multiple organs may affect either pharmacokinetics or pharmacodynamics during aging. Changes in body composition occurring with advancing age, reduced liver mass and perfusion, and reduced renal excretion may affect either pharmacokinetics or pharmacodynamics. These issues need to be taken into account when prescribing antimicrobial agents to older complex patients taking multiple drugs. Interventions aimed at improving the appropriateness and safety of antimicrobial prescriptions have been proposed. Educational interventions targeting physicians may improve antimicrobial prescriptions. Antimicrobial stewardship programmes have been found to reduce the length of hospital stay and improve safety in hospitalized patients, and their use in long-term care facilities is worth testing. Computerized prescription and decision support systems, as well as interventions aimed at improving antimicrobial agents dosage in relation to kidney function, may also help to reduce the burden of interactions and inherent costs.

Safety and pharmacokinetics of oral delta-9-tetrahydrocannabinol in healthy older subjects: a randomized controlled trial

There is a great concern about the safety of THC-based drugs in older people (≥65 years), as most of THC-trials did not include such group. In this phase 1, randomized, double-blind, double-dummy, placebo-controlled, cross-over trial, we evaluated the safety and pharmacokinetics of three oral doses of Namisol(®), a novel THC in tablet form, in older subjects. Twelve healthy older subjects (6 male; mean age 72±5 years) randomly received a single oral dose of 3mg, 5mg, or 6.5mg of THC or matching placebo, in a crossover manner, on each intervention day. The data for 11 subjects were included in the analysis. The data of 1 subject were excluded due to non-compliance to study medication. THC was safe and well tolerated. The most frequently reported adverse events (AEs) were drowsiness (27%) and dry mouth (11%). Subjects reported more AEs with THC 6.5mg than with 3mg (p=0.048), 5mg (p=0.034) and placebo (p=0.013). There was a wide inter-individual variability in plasma concentrations of THC. Subjects for whom the Cmax fell within the sampling period (over 2h), Cmax was 1.42-4.57ng/mL and Tmax was 67-92min. The AUC0-2h (n=11) was 1.67-3.51ng/mL. Overall, the pharmacodynamic effects of THC were smaller than effects previously reported in young adults. In conclusion, THC appeared to be safe and well tolerated by healthy older individuals. Data on safety and effectiveness of THC in frail older persons are urgently required, as this population could benefit from the therapeutic applications of THC.

Interpretation in cross-language research: tongues-tied in the health care interview?

Medication prescribing and use is a normative aspect of health care for the elderly, rendering medication taking by elderly persons problematic. In an earlier qualitative study, we examined how medicine-use is negotiated (used/refused/resisted, and assessed against expected outcomes) by older persons with limited fluency in English-the main language of health care in the study setting. In the present article, we describe a reflexive methodological review of that study's design, with a particular focus placed on interpreter-mediated data collection. We illustrate that what was heard in open-ended interviews (what became data) was influenced by not only what was asked and how, but also by how the interpreter 'heard' and conveyed dialogue to and from study participants. We illustrate differing accounts of the dialogue between an interviewer and participant provided via real-time interpretation and through a reflexive re-interpretation of talk-to-text transcripts, reflecting the different stakes in the research, and different capital available to study- and review-interpreters. Implications for research design and practice of cross-cultural and cross-language research are highlighted.

Severity and management of drug-drug interactions in acute geriatric patients

BACKGROUND

Previous studies have investigated the prevalence of drug-drug interactions (DDIs) among the elderly in different care settings, but data describing the frequency and management of DDIs among acute geriatric patients appear to be absent.

OBJECTIVE

The aim of this study was to investigate the severity and interdisciplinary management of DDIs in patients admitted to an acute geriatric ward.

METHODS

The study was conducted at Oslo University Hospital, Norway, over a period of 19 weeks in 2010/11. On admission and daily during the hospital stay, prescribed medications were reviewed by pharmacists to identify DDIs with the aid of web-based databases. DDIs defined to be of potential clinical relevance, i.e., those classified as "major" (generally avoid) or "moderate" (precautions recommended), were following assessments by pharmacists presented at interdisciplinary meetings with geriatricians and nurses, and discussed in relation to the possible implementation of monitoring actions or changes in prescribing. The odds for prescribing changes were compared in relation to DDI type ("pharmacokinetic" vs. "pharmacodynamic") and severity ("major" vs. "moderate"). The project group retrospectively assessed the possible causal relationships between hospitalizations and DDIs.

RESULTS

The pharmacists identified 245 DDIs of major (n = 13) or moderate (n = 232) severity in 80 (63.5 %) of the 126 patients included on admission and/or during hospitalization. In 94 of 162 cases where the pharmacists alerted the geriatricians (58.0 %), prescribing changes or monitoring actions were implemented. Prescribing changes (n = 38) were performed significantly more often for major than for moderate DDIs [odds ratio (OR) 3.8; 95 % confidence interval (CI) 1.2-12.2, p = 0.03], and significantly more often for pharmacokinetic than for pharmacodynamic DDIs (OR 4.9; 95 % CI 2.2-10.9, p < 0.01). For 28 of 126 patients (22.2 %), a causal relationship between hospitalizations and DDIs was assessed as "possible".

CONCLUSIONS

The present study shows that acute geriatric patients are frequently exposed to DDIs for which active management is recommended in order to avoid unfavorable clinical outcomes. The integration of pharmacists into interdisciplinary teams could prevent potentially severe DDIs in the elderly.

Potentially inappropriate medication use in older people with cancer: prevalence and correlates

OBJECTIVES

Potentially inappropriate medication (PIM) use has been associated with an increase in adverse drug events, hospitalization and mortality. This study investigated the prevalence and factors associated with PIM use in patients presenting to a medical oncology outpatient clinic.

MATERIALS AND METHODS

Consecutive patients (n=385) aged ≥ 70 years referred to a medical oncology outpatient clinic between January 2009 and July 2010 completed a structured data collection instrument. The instrument assessed medication use, diagnoses, self-reported falls in the previous six months, pain (10-point visual analog scale [VAS]) and distress (10-point VAS). Frailty was defined using exhaustion, weight loss, Karnofsky Performance Scale, instrumental activities of daily living and physical function. PIM use was defined by the Beers Criteria. Logistic regression was used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with PIM use.

RESULTS

In total, 26.5% (n=102) of the sample used ≥1 PIM. The five most prevalent classes of PIMs were benzodiazepines (n=34, 8.8%), tricyclic antidepressants (n=16, 4.2%), alpha-adrenoreceptor antagonists (prazosin) (n=15, 3.9%), propulsives (metoclopramide) (n=15, 3.9%) and non-steroidal anti-inflammatory drugs (n=14, 3.6%). In multivariate analyses, PIM use was associated with age 75-79 years (OR 1.83; 95%CI 1.02-3.26) compared to age 70-74 years, using ≥ 5 medications (OR 4.10; 95%CI 2.26-7.44) compared to <5 medications and being frail (OR 3.05; 95%CI 1.18-7.87) compared to being robust.

CONCLUSION

More than one quarter of older people with cancer used one or more PIMs, and this was associated with being frail compared to being robust.

In vivo animal stroke models: a rationale for rodent and non-human primate models

On average, every four minutes an individual dies from a stroke, accounting for 1 out of every 18 deaths in the United States. Approximately 795,000 Americans have a new or recurrent stroke each year, with just over 600,000 of these being first attack [1]. There have been multiple animal models of stroke demonstrating that novel therapeutics can help improve the clinical outcome. However, these results have failed to show the same outcomes when tested in human clinical trials. This review will discuss the current in vivo animal models of stroke, advantages and limitations, and the rationale for employing these animal models to satisfy translational gating items for examination of neuroprotective, as well as neurorestorative strategies in stroke patients. An emphasis in the present discussion of therapeutics development is given to stem cell therapy for stroke.

Possible adverse drug events leading to hospital admission in a Brazilian teaching hospital

OBJECTIVES

Drug safety problems can lead to hospital admission. In Brazil, the prevalence of hospitalization due to adverse drug events is unknown. This study aims to estimate the prevalence of hospitalization due to adverse drug events and to identify the drugs, the adverse drug events, and the risk factors associated with hospital admissions.

METHOD

A cross-sectional study was performed in the internal medicine ward of a teaching hospital in São Paulo State, Brazil, from August to December 2008. All patients aged ≥18 years with a length of stay ≥24 hours were interviewed about the drugs used prior to hospital admission and their symptoms/complaints/causes of hospitalization.

RESULTS

In total, 248 patients were considered eligible. The prevalence of hospitalization due to potential adverse drug events in the ward was 46.4%. Overprescribed drugs and those indicated for prophylactic treatments were frequently associated with possible adverse drug events. Frequently reported symptoms were breathlessness (15.2%), fatigue (12.3%), and chest pain (9.0%). Polypharmacy was a risk factor for the occurrence of possible adverse drug events.

CONCLUSION

Possible adverse drug events led to hospitalization in a high-complexity hospital, mainly in polymedicated patients. The clinical outcomes of adverse drug events are nonspecific, which delays treatment, hinders causality analysis, and contributes to the underreporting of cases.

Clinical implications of ageing for the management of IBD

As the global population ages, the number of older people (≥65 years) living with IBD is expected to increase. IBD therapeutics have advanced considerably over the past few decades with the introduction of multiple steroid-sparing agents as well as numerous clinical trials that have tested new therapeutic targets. However, the current paradigms for IBD management might not be directly translatable to older patients with IBD. Age-related factors such as immunodeficiency relative to younger patients, comorbidity, polypharmacy and diminished physical reserve directly or indirectly affect the natural history of their disease. This Review highlights how these age-associated variables can affect older patients with IBD and also illustrates the multiple gaps in our current knowledge of IBD in the elderly.

Association between potentially inappropriate medications from the Beers criteria and the risk of unplanned hospitalization in elderly patients

BACKGROUND

Predisposition to adverse drug events with advancing age has led to the development of lists of potentially inappropriate medications (PIMs) to be avoided in the elderly, such as the Beers Criteria. The prevalence of Beers medications has been studied widely, but it is still unclear whether PIM use is predictive of adverse events in older people.

OBJECTIVES

To examine potential associations between exposure to PIMs from the general Beers list and unplanned hospitalizations in elderly Western Australians.

METHODS

Using an enhanced case-time-control design and conditional logistic regression applied to the pharmaceutical claims and other linked health data of 251 305 Western Australians aged ≥65 years (1993-2005), odds ratios for unplanned hospitalization were obtained, from which attributable fractions, number and proportion of hospitalizations associated with drug exposure were derived.

RESULTS

Based on the health profiles of 383 150 hospitalized index subjects, overall PIM exposure was associated with an elevated risk of unplanned hospitalization (adjusted odds ratio = 1.18; 95% confidence interval = 1.15-1.21), this estimated risk increasing with the number of different PIMs and PIM quantity taken. Fifteen percent of unplanned hospitalizations in exposed index subjects (1980 per year) were attributed to PIM exposure. Patients taking meperidine (pethidine), nitrofurantoin, promethazine, indomethacin, and thioridazine appeared to be at particularly high risk of unplanned hospitalization, whereas temazepam, oxazepam, diazepam, digoxin, amiodarone, ferrous sulfate, and naproxen were attributed the greatest numbers of unplanned hospitalizations.

CONCLUSIONS

Due caution prescribing Beers medications in the elderly seems justified, paying particular attention to PIMs listed above and to the concurrent use of multiple PIMs. Our results also support the retention of specific medications on PIM lists in future developments.

Description of a systematic pharmaceutical care approach intended to increase the appropriateness of medication use by elderly patients

BACKGROUND & AIMS

The pharmaceutical care practice represents a model of responsible pharmacist involvement in the pharmacotherapy optimization of various population groups, including the elderly, known to be at risk for drug-related problems. Romanian pharmacists could use validated pharmaceutical care experiences to confirm their role as health-care professionals. This descriptive research presents the application in two real and different environments of practice of a structured pharmaceutical care approach conceived as the basis for a medication review activity and aiming at the identification and resolution of the drug related problems in the elderly.

PATIENTS AND METHODS

Two patients with similar degree of disease-burden complexity, receiving care in different health-care environments (The Geriatric Ward of the Royal Victoria Hospital from the McGill University Health Centre in Montréal, Québec, Canada, in November 2010, and an urban nursing-home facility in Cluj-Napoca, Romania, in March 2011), were chosen for the analysis. One clinical pharmacist suggested solutions for the management of each of the active drug-related problems identified, using the systematic pharmaceutical care approach and specific published geriatric pharmacotherapy recommendations. The number of the drug-related problems identified and the degree of the care-team acceptance of the pharmacists' solutions were noted for each patient.

RESULTS

The pharmacist found 6 active drug-related problems for the hospitalized patient (72 year-old, Chronic Disease Score 9) and 7 potential ones for the nursing-home resident (79 year-old, Chronic Disease Score 8), involving misuse, underuse and overuse of medications. Each patient had 3 geriatric syndromes at baseline. The therapy changes suggested by the pharmacist were implemented for the hospitalized patient, through collaboration with the health-care team. For the nursing home resident, the pharmacist identified the need for additional 6 medications and safety and efficacy arguments to cease 7 initial therapies, simplifying the therapeutic daily schedule (from 24 daily doses to 15).

CONCLUSION

The pharmacist's potential contribution to the optimization of the Romanian elderly patients' pharmacotherapy needs further exploration, as potential drug related problems reported as characteristic for this population were easily identified. The presented structured and validated model of pharmaceutical care approach could be used to this end. Its dissemination and use could be encouraged along with the enhancement of pharmacotherapy information and care team collaboration skills.

Are high-care nursing home residents at greater risk of unplanned hospital admission than other elderly patients when exposed to Beers potentially inappropriate medications?

AIM

To compare the risk of unplanned hospitalization in high-care nursing home residents taking Beers potentially inappropriate medications (PIM) against that of other elderly.

METHODS

Using an enhanced case-time-control design and conditional logistic regression applied to the pharmaceutical claims and other linked data of 245436 Western Australians aged ≥ 65 years (1993-2005), the study derived odds ratios for unplanned hospitalization in each group, from which attributable fractions, numbers, proportions and rates of PIM-related admissions were derived.

RESULTS

Overall, 383150 unplanned hospitalizations were identified. PIM exposure was associated with a similar proportional increase in unplanned hospitalizations in high-care nursing home residents as in other older people; adjusted OR 1.21 (95% CI 1.10-1.34; attributable fraction 17.5%) versus OR 1.19 (95% CI 1.16-1.21; attributable fraction 15.7%). However, high-care nursing home residents had much higher estimated rates of hospitalizations attributed to Beers medications than other elderly (3951 vs 1394 per 100000 person-years). The relative risk of unplanned hospitalization rose similarly in both groups with increasing numbers of different PIM taken (OR 5.1 for 10 vs 0 PIM), but was affected more markedly by 3-month PIM consumption in nursing home residents (OR 4.85, 95% CI 2.40-9.83 for 900 vs 0 PIM daily doses) than in other older adults (OR 2.10, 95% CI 1.73-2.55).

CONCLUSIONS

High-care nursing home residents do not appear to have a greater relative risk of unplanned hospitalization when given PIM, but do incur a higher absolute burden than other older adults. Physicians should exert caution with Beers medications in all older patients, restricting the number of different PIM and PIM quantity prescribed whenever possible.

General practitioners’ attitudes towards decision-supported prescribing: An analysis of the Dutch primary care sector

The use of multiple drugs by patients increases the risk of medical problems. Clinical decision support could assist general practitioners with prescribing but is underused. This article aims to investigate the attitudes of general practitioners towards using decision support systems. A survey was distributed among 500 Dutch general practitioners. Virtually all 184 respondents indicated having a clinical information system, while only 21 percent indicated having a decision support plug-in; this correlated with their use of medical formularies. Only use of one of the medical formularies correlated with the number of recognized underprescription problems. General practitioners’ attitudes toward a newly proposed system aiding them with polypharmacy prescribing were mainly positive (57%); the perceived usefulness correlated with output quality (p = .000), time investment (p = .000), and financial stimuli (payability: p = .000 and reimbursement: p = .015) but not with job relevance. Dutch general practitioners are thus likely to adopt the proposed system under the conditions that it improves prescription quality and does not require extensive investments of time or money.

Older adults' satisfaction with a medication dispensing device in home care

INTRODUCTION

Older adults with multiple chronic conditions face the complex task of medication management involving multiple medications of varying doses at different times. Advances in telehealth technologies have resulted in home-based devices for medication management and health monitoring of older adults. We examined older adults' perceptions of a telehealth medication dispensing device as part of a clinical trial involving home healthcare clients, nurse coordination and use of the medication dispensing device.

METHODS

Ninety-six frail older adult participants who used the medication dispensing device for 12 months completed a satisfaction survey related to perceived usefulness and reliability. Results were analyzed and grouped by themes in the following areas: Ease of Use, Reliability, Medication Management Assistance, Routine Task Performance and Acceptability.

RESULTS

Nearly all participants perceived the medication dispensing device as very easy to use, very reliable and helpful in the management of their medications. Eighty-four percent of participants expressed a desire to use the machine in the future.

CONCLUSION

The technology-enhanced medication management device in this study is an acceptable tool for older adults to manage medication in collaboration with home care nurses. Improved usability and cost models for medication dispensers are areas for future research.

The economic burden of inappropriate drug prescribing, lack of adherence and compliance, adverse drug events in older people: a systematic review

Adverse drug events (ADEs) are an increasingly relevant issue for healthcare systems as they are associated with poorer health outcomes and avoidable misuse of resources. The rates of ADEs are higher in the elderly population, as many older patients have comorbidities, multiple drug prescriptions and deteriorated physical and cognitive functioning. The occurrence of ADEs can lead to a perceived lack of therapy efficacy and further underuse or suboptimal adherence in elderly people, with detrimental clinical outcomes. The present article systematically reviews the studies evaluating the economic impact of ADEs occurring as consequence of poor therapy adherence, inappropriate drug use, underuse of effective treatments and poor adherence, medication errors, drug-drug and drug-disease interactions.A Medline systematic literature review of studies evaluating the economic consequences of inappropriate drug prescribing, lack of adherence and compliance, ADEs in older people was performed. English-language articles were screened through a three-step approach (title review, abstract review, full article review) to select pertinent studies quantitatively evaluating costs. We systematically reviewed evidence from767 articles. After title, abstract and full text review, 21 articles were found to measure economic implications ofADEs, inappropriate drug prescribing and poor adherence in elderly patients. Studies suggested that the economic impact of these undesired effects is substantial: hospital costs were the main cost driver, with a relevant part of them being preventable (consequences of inappropriate prescribing). Healthcare costs for unused drug wastage and destruction were also surprisingly high.Although economic evidence in elderly patients is still limited, all studies seemed to confirm that the financial burden due to pharmacological treatment issues is relevant in elderly people. Including economic effects of adverse events in pharmacoeconomic analysis would be beneficial to improve the reliability of results. Preliminary evidence suggests that programmes aimed at comprehensively assessing geriatric conditions, detecting 'high-risk' prescriptions and training patients to comply with prescribed therapies could be costeffective measures to reduce the burden of ADEs.

Rational use of medicines: prescribing indicators at different levels of health care

This multicenter study aimed to investigate prescribing patterns of drugs at different levels of health care delivery in university-affiliated outpatient clinics located in eight cities in the South and Midwest of Brazil. All prescriptions collected were analyzed for various items, including WHO prescribing indicators. A total of 2,411 prescriptions were analyzed, and 469 drugs were identified. The number of drugs prescribed per encounter, the frequency of polypharmacy, and the percentage of encounters with at least one injection or antibiotic prescribed were higher in centers providing primary health care services, compared to those where this type of care is not provided. Most drugs (86.1%) were prescribed by generic name. In centers with primary health care services, drug availability was higher, drugs included in the National and Municipal Lists of Essential Medicines were more frequently prescribed, and patients were given more instructions. However, warnings and non-pharmacological measures were less frequently recommended. This study reveals trends in drug prescribing at different levels of health care delivery in university-affiliated outpatient clinics and indicates possible areas for improvement in prescribing practices.

[Less can be more - drug therapy in the elderly]

A significant proportion of the elderly population is affected by multimorbidity and polypharmacy. Drug safety in this population is characterised by age-associated changes in pharmacokinetics and pharmacodynamics, an increased risk for drug-drug interactions, an unmanageable situation of side effects and co-morbidities, and a questionable adherence to complex therapies. Moreover, elderly multimorbid patients are usually not enrolled in clinical trials, and therefore the evidence for efficacy and safety of drugs is sparse. Many practice guidelines do not consider multimorbidity and age-associated changes in physical function, cognition and reduced life expectancy. Most published approaches to reducing polypharmacy such as algorithms and checklists have not yet been validated prospectively in randomised, controlled trials. However, some studies have shown the feasibility of stopping medications, in some cases accompanied by remarkable improvements of quality of life. (As supplied by publisher).

Physical activity is inversely related to drug consumption in elderly patients with cardiovascular events

Elderly patients with cardiovascular events are characterized by high drug consumptions. Whether high drug consumptions are related to physical activity is not known. In order to examine whether physical activity is related to drug consumption in the elderly, patients older than 65 years (n = 250) with a recent cardiovascular event were studied. Physical activity was analyzed according to the Physical Activity Scale for the Elderly (PASE) score and related to drug consumption. PASE score was 72.4 ± 45.0 and drug consumption was 8.3 ± 2.2. Elderly patients with greater comorbidity took more drugs (8.7 ± 2.1) and are less active (PASE = 64.4 ± 50.6) than patients with Cumulative Illness Rating Scale severity score higher than 1.8 than those with a score lower than 1.8 (76.3 ± 41.4, p < 0.05, and 8.0 ± 2.0, p = 0.006, respectively). Multivariate analysis correlation confirmed that PASE score is negatively associated with drug consumption (β = −0.149, p = 0.031), independently of several variables including comorbidity. Thus, physical activity is inversely related to drug consumption in elderly patients with cardiovascular events. This inverse relationship may be attributable to the high degree of comorbidity observed in elderly patients in whom poor level of physical activity and high drug consumption are predominant.

Primary non-adherence to prescribed medication in general practice: lack of influence of moderate increases in patient copayment

BACKGROUND

Primary non-adherence refers to the patient not redeeming a prescribed medication at some point during drug therapy. Research has mainly focused on secondary non-adherence. Prior to this study, the overall rate of primary non-adherence in general practice in Iceland was not known.

OBJECTIVES

To determine the prevalence of primary non-adherence, test whether it is influenced by a moderate increase in patient copayment implemented in 2010 and examine the difference between copayment groups (general versus concession patients).

METHODS

A population-based data linkage study, wherein prescriptions issued electronically by 140 physicians at 16 primary health care centres in the Reykjavik capital area during two periods before and after increases in copayment were matched with those dispensed in pharmacies, the difference constituting primary non-adherence (population: 200&emsp14;000; patients: 21&emsp14;571; prescriptions: 22&emsp14;991). Eight drug classes were selected to reflect symptom relief and degree of copayment. Two-tailed chi-square test and odds ratios for non-adherence by patient copayment groups were calculated.

RESULTS

The rate of primary non-adherence was 6.2%. It was lower after the increased copayment, reaching statistical significance for hypertensive agents, non-steroidal anti-inflammatory drugs (NSAIDs) and antipsychotics. Generally, primary non-adherence, except for antibacterials and NSAIDs, was highest in old-age pensioners.

CONCLUSIONS

Primary non-adherence in Icelandic general practice was within the range of prior studies undertaken in other countries and was not adversely affected by the moderate increase in patient copayment. Older patients showed a different pattern of primary non-adherence. This may possibly be explained by higher prevalence of medicine use.

Gender and polypharmacotherapy in the elderly: a clinical challenge

Polypharmacotherapy is a major concern in the elderly and especially in older women after the age of 80. It results from the intake of prescription and non-prescription drugs, being often a problem of evidence-based therapy. Besides the fact that women live longer than men and outnumber them, reasons for polypharmacy in women are diverse and include a different attitude towards intake of drugs between men and women, the propensity of women to rather see a physician and talk about their problems, the load of family responsibility as women are the main caregivers within a family, the influence of physician sex on patient care, the level of education, social deprivation and self-rated health. Women are more often prescribed potentially inappropriate medication and more often become victims of adverse drug reactions. This is not only due to the number and quality of drugs prescribed but also to differences in pharmacokinetics and - dynamics which make them more vulnerable to drug exposure. Thus, inappropriate prescribing contributes to hospitalization, poor quality of life, costs, compliance issues and poor outcomes. More preclinical and clinical studies with elderly patients and especially elderly women are needed to study the underlying mechanisms of the pharmacologic differences and obtain more insight into the difference in risk between men and women. Attention to prescribing of medications, consistent review of medication lists, and reevaluation of indications and outcomes of prescribing are essential to ensure that drugs are used appropriately in elderly women, polypharmacy is minimized and safety for patients is maximized.

Assessment of pharmacotherapeutic safety of medical prescriptions for elderly residents in a long-term care facility

The present study aimed to estimate the prevalence of elderly using potentially inappropriate medications (PIM) and with occurrence of potentially hazardous drug interactions (PHDI); to identify the risk factors for the prescription of PIM and to evaluate the impact of pharmaceutical intervention (PI) for the prescription of safer therapeutic alternatives. Therefore, a cross-sectional study was performed in a long-term care facility in São Paulo State, between December/2010 and January/2011. The medical records of the patients >60 years old who took any drugs were consulted to assess the pharmacotherapeutic safety of the medical prescriptions, in order to identify PIM and PHDI, according to the Beers (2003) and World Health Organization criteria, respectively. PI consisted of a guidance letter to the physician responsible for the institution, with the suggestions of safer equivalent therapeutics. Approximately 88% of the elderly took at least one drug, and for 30% of them the PIM had been prescribed. Most of the PIM identified (53.4%) act on the central nervous system. Among the 13 different DI detected, 6 are considered PHDI. Polypharmacy was detected as a risk factor for PIM prescription. After the PI there was no change in medical prescriptions of patients who had been prescribed PIM or PHDI. The data suggests that PI performed by letter, as the only interventional, method was ineffective. To contribute it a wide dissemination of PIM and PHDI among prescriber professionals is necessary for the selection of safer treatment for elderly. Additionally, a pharmacist should be part of the health care team in order to help promote rational use of medicines.

Riscos da interação droga-nutriente em idosos de instituição de longa permanência

O objetivo do estudo foi verificar riscos da interação droga-nutriente nos idosos residentes em Instituição de Longa Permanência. Trata-se de estudo descritivo, de abordagem quantitativa, realizado em 73 idosos. A coleta dos dados ocorreu em 2008, através da análise dos prontuários, história dietética e avaliação do IMC. Os dados evidenciaram que os medicamentos mais utilizados foram do sistema nervoso e cardiovascular, totalizando 66% das prescrições. Entre 375 medicamentos prescritos, 166 fazem algum tipo de interação, 32,0% diminuem o efeito de absorção do fármaco quando há utilização de cafeína e 14,3% diminuem absorção de vitamina B12. A utilização de diversos medicamentos de uso contínuo pode acarretar prejuízo na absorção de nutrientes, aumentando o risco de desnutrição em idosos. Torna-se indispensável a ação da equipe de saúde, através da avaliação criteriosa dos medicamentos administrados, dietoterapia e a interação entre os mesmos, para beneficiar idosos com melhor aproveitamento da terapêutica e melhoria das condições nutricionais.

Discrepancies in Medication Information for the Primary Care Physician and the Geriatric Patient at Discharge

BACKGROUND:

Medication discrepancies in discharge medication lists can lead to medication errors and adverse drug events following discharge.

OBJECTIVE:

To determine the incidence and type of discrepancies between the discharge letter for the primary care physician and the patient discharge medication list as well as identify possible patient-related determinants for experiencing discrepancies.

METHODS:

A retrospective, single-center, cohort study of patients discharged from the acute geriatric department of a Belgian university hospital between September 2009 and April 2010 was performed. Medications listed in the discharge letter for the primary care physician were compared with those in the patient discharge medication list. Based on the clinical pharmacist–acquired medication list at hospital admission and the medications administered during hospitalization, we determined for every discrepancy whether the medication listed in the discharge letter or the patient discharge medication list was correct.

RESULTS:

One hundred eighty-nine discharged patients (mean [SD] age 83.9 [5.7] years, 64.0% female) were included in the study. Almost half of these patients (90; 47.6%) had 1 or more discrepancies in medication information at discharge. The discharge letters were often more complete and accurate than the patient discharge medication lists. The most common discrepancies were omission of a brand name in the patient discharge medication list and omission of a drug in the discharge letter. Increasing numbers of drugs in the discharge medication list (OR 1.19; 95% CI 1.07 to 1.32; p = 0.001) and discharge letter (OR 1.18; 95% CI 1.07 to 1.32; p = 0.001) were associated with a higher risk for discrepancies.

CONCLUSIONS:

Discrepancies between the patient discharge medication list and the medication information in the discharge letter for the primary care physician occur frequently. This may be an important source of medication errors, as confusion and uncertainty about the correct discharge medications can originate from these discrepancies. Increasing numbers of drugs involve a higher risk for discrepancies. Medication reconciliation between both lists is warranted to avoid medication errors.

Pharmacokinetics and pharmacodynamic changes associated with aging and implications for drug therapy

The population of older adults continues to increase, and polypharmacy in this population is more the rule than the exception. Physiologic changes that occur with aging result in multiple alterations to the pharmacokinetics and pharmacodynamics of drugs, which, in turn, increase the risk of adverse drug reactions. Consideration of initial dose adjustment, along with frequent medication reconciliation and analysis of the medication list, are keys to providing optimal pharmaceutical care for elderly patients.

Effect of Medication Reconciliation at Hospital Admission on Medication Discrepancies During Hospitalization and at Discharge for Geriatric Patients

Background:

Medication discrepancies have the potential to cause harm. Medication reconciliation by clinical pharmacists aims to prevent discrepancies and other drug-related problems.

Objective:

To determine how often discrepancies in the physician-acquired medication history result in discrepancies during hospitalization and at discharge. Secondary objectives were to determine the influence of clinical pharmacists’ interventions on discrepancies and to investigate possible patient-related determinants for experiencing discrepancies.

Methods:

This was a retrospective, single-center, cohort study of patients who were admitted to the acute geriatric department of a Belgian university hospital and followed up by clinical pharmacists between September 2009 and April 2010. Patients were limited to those 65 years or older who were taking 1 or more prescription drug. Medication reconciliation at admission, during hospitalization, and at discharge was conducted by an independent pharmacist who gathered information via chart reviews.

Results:

The reconciliation process at admission identified 681 discrepancies in 199 patients. Approximately 81.9% (163) of patients had at least 1 discrepancy in the physician-acquired medication history. The clinical pharmacists performed 386 interventions, which were accepted in 279 cases (72.3%). A quarter of the medication history discrepancies (165; 24.2%) resulted in discrepancies during hospitalization, mostly because the intervention was not accepted. At discharge, 278 medication history discrepancies (40.8%) resulted in discrepancies in the discharge letter, accounting for 50.2% of all 554 discrepancies identified in the discharge letters. The likelihood for experiencing discrepancies at admission increased by 47% for every additional drug listed in the medication history.

Conclusions:

Discrepancies in the physician-acquired medication history at admission do not always correlate with discrepancies during hospitalization because of clinical pharmacists’ interventions; however, discrepancies at admission may be associated with at least half of the discrepancies at discharge. Clinical pharmacist–conducted medication reconciliation can reduce these discrepancies, provided the erroneous information in the physician-acquired medication history is corrected and each intentional change in the medication plan is well documented during hospitalization and at discharge.

Drug use in centenarians compared with nonagenarians and octogenarians in Sweden: a nationwide register-based study

BACKGROUND

the number of centenarians increases rapidly. Yet, little is known about their health and use of medications.

OBJECTIVE

to investigate pharmacological drug use in community-dwelling and institutionalised centenarians compared with nonagenarians and octogenarians.

METHODS

we analysed data on dispensed drugs for centenarians (n = 1,672), nonagenarians (n = 76,584) and octogenarians (n = 383,878) from the Swedish Prescribed Drug Register, record-linked to the Swedish Social Services Register. Multivariate logistic regression analysis was used to analyse whether age was associated with use of drugs, after adjustment for sex, living situation and co-morbidity.

RESULTS

in the adjusted analysis, centenarians were more likely to use analgesics, hypnotics/sedatives and anxiolytics, but less likely to use antidepressants than nonagenarians and octogenarians. Moreover, centenarians were more likely to use high-ceiling diuretics, but less likely to use beta-blockers and ACE-inhibitors.

CONCLUSIONS

centenarians high use of analgesics, hypnotics/sedatives and anxiolytics either reflects a palliative approach to drug treatment in centenarians or that pain and mental health problems increase into extreme old age. Also, centenarians do not seem to be prescribed cardiovascular drug therapy according to guidelines to the same extent as nonagenarians and octogenarians. Whether this reflects an age or cohort effect should be evaluated in longitudinal studies.

Institutionalization as a risk factor for inappropriate drug use in the elderly: a Swedish nationwide register-based study

BACKGROUND

Few studies have investigated institutionalization as a potential risk factor for potentially inappropriate drug use (PIDU). Sweden now has unique possibilities for comparisons of drug use in large populations of institutionalized and home-dwelling elderly through linkage of the Swedish Prescribed Drug Register (SPDR) with the Swedish Social Services Register.

OBJECTIVE

To compare PIDU in institutionalized versus home-dwelling elderly persons in Sweden.

METHODS

We conducted a cross-sectional retrospective study of 1,260,843 home-dwelling and 86,721 institutionalized elderly individuals. We analyzed data on age, sex, and dispensed drugs for individuals aged 65 years or older registered in the SPDR from July to September 2008. Data on type of housing were retrieved from the Social Services Register. The main outcome measures of PIDU were use of anticholinergic drugs, long-acting benzodiazepines, concurrent use of 3 or more psychotropics, and potentially serious drug-drug interactions (DDIs).

RESULTS

Thirty percent of the institutionalized and 12% of the home-dwelling elderly were exposed to PIDU. Living in an institution was strongly associated with overall PIDU (OR 2.36; 95% CI 2.29 to 2.44), use of anticholinergic drugs (OR 2.58; 95% CI 2.48 to 2.68), long-acting benzodiazepines (OR 1.50; 95% CI 1.41 to 1.60), and concurrent use of 3 or more psychotropics (OR 7.26; 95% CI 6.96 to 7.59), after controlling for age, sex, and number of drugs (used as proxy for comorbidity). However, institutionalization was associated with a lower probability of potentially serious DDIs (OR 0.60; 95% CI 0.55 to 0.65).

CONCLUSIONS

Our results indicate that institutionalization is a potential risk factor for PIDU. This implies that more cautious prescribing is warranted in institutions, where the frailest and most vulnerable elderly individuals reside. Research is needed to identify underlying risk factors for PIDU within these settings.

Self-reported adverse drug events and the role of illness perception and medication beliefs in ambulatory heart failure patients: A cross-sectional survey

BACKGROUND

Identifying patients with heart failure (HF) who are at risk of experiencing symptomatic adverse drug events (ADEs) is important for improving patient care and quality of life. Several demographic and clinical variables have been identified as potential risk factors for ADEs but limited knowledge is available on the impact of HF patients' beliefs and perceptions on their experience of ADEs.

OBJECTIVE

The purpose of the study was to identify the relationship between HF patients' illness perception and medication beliefs and self-reported ADEs.

DESIGN

A cross-sectional survey was performed between November 2008 and March 2009.

SETTINGS

One university medical centre, two regional hospitals and 20 general practitioners in the Netherlands participated in the study.

PARTICIPANTS

495 patients with HF were included.

METHODS

Patients completed the validated Revised Illness Perception Questionnaire (IPQ-R) and the Beliefs about Medication Questionnaire (BMQ) which collected data on their illness perception and medication beliefs. In addition, data on ADEs as experienced in the previous four weeks were collected through an open-ended question and a symptom checklist. Multivariate logistic regression was performed to identify factors associated with these ADEs.

RESULTS

In total, 332 (67%) patients had experienced ADEs in the previous four weeks, of whom 28% reported dry mouth, 27% dizziness and 19% itchiness as the most prevalent. In the adjusted multivariate analysis, disease-related symptoms (illness identity) (OR for 1-5 symptoms 3.57; 95% CI 2.22-5.75, OR for >5 symptoms 7.37; 95% CI 3.44-15.8), and general beliefs about medication overuse (OR 1.07; 95% CI 1.01-1.13) were independently associated with experiencing ADEs, whereas none of the demographic or clinical factors were significant.

CONCLUSIONS

HF patients who perceive a high number of disease symptoms and have negative medication beliefs are at higher risk of experiencing self-reported ADEs. We suggest that future studies and interventions to improve ADE management should focus on negative medication beliefs and assisting patients in differentiating disease symptoms from ADEs.

Becoming old as a 'pharmaceutical person': negotiation of health and medicines among ethnoculturally diverse older adults

Because medication prescribing and use have become a normative aspect of health care for older adults, we seek to understand how individuals navigate prescribed-medication use within the context of aging. We reasoned that, for those who are ambulatory, medication use is likely influenced by ethnocultural meanings of health and experiences with alternative approaches to health care. Accordingly, we conducted a qualitative study, with in-depth interviews, on a diverse sample of older adults in order to identify elderly persons' perceptions and uses of medicines. Our findings depict older adults as active agents--who draw on a lifetime of experience and knowledge--who take responsibility for adherence (or non-adherence) to medicines and their associated effects on their own bodies. We represent the older person as a "pharmaceutical person" whose experiences of aging are inextricably tied up with the negotiation of medicine-reliant health care.

Antimuscarinics for the treatment of overactive bladder: understanding the role of muscarinic subtype selectivity

INTRODUCTION AND HYPOTHESIS

Antimuscarinic agents appear to exert their therapeutic activity in overactive bladder (OAB) via blockade of the M(3) muscarinic receptor subtype. Antimuscarinics are broadly similar in efficacy, but their safety and tolerability profiles vary, which may reflect differences in muscarinic receptor selectivity profiles.

METHODS

This review of available literature aims to determine whether antimuscarinic agents with greater M(3) selectivity have clinical advantages over less selective drugs.

RESULTS

Antimuscarinic agents differ widely in their propensity to cause cognitive and cardiovascular (CV) effects, which appear mainly to be related to differences in their relative selectivity for binding to non-M(3) receptors, including M(1) receptors in the brain and cardiac M(2) receptors.

CONCLUSIONS

Cognitive and CV effects are especially pertinent for the OAB patient who tends to be older with various comorbidities and is often taking multiple medications. Hence, it is important to consider the risk/benefit balance of antimuscarinic agents when selecting OAB treatment.

Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home

BACKGROUND

Accurate medication histories at hospital admission are an important element of medication safety. Discrepancies may have clinically significant consequences, especially in the elderly population.

OBJECTIVE

To assess the clinical pharmacist's performance in obtaining patients' medication histories and in reconciling these data with the medical records and medication orders and whether the patients' residential situation prior to hospitalization influences the number of drug discrepancies.

METHODS

A prospective observational study was conducted at a 29-bed acute geriatric ward of a Belgian university hospital. Medication histories acquired by clinical pharmacists were compared with those documented in the medical records by the attending physicians. All discrepancies were identified and categorized by an independent pharmacist and were scored for their clinical relevance in consensus by a senior internist and a senior geriatrician.

RESULTS

Of the 215 screened geriatric (aged ≥65 years) patients admitted between October 27, 2007, and September 23, 2008, 197 were enrolled in the study. For patients living in the community, as well as those residing in a nursing home prior to hospitalization, clinical pharmacists identified significantly more preadmission drugs compared with physicians, with a median number of 8 correctly identified medications versus 6, respectively (p < 0.001). Extra identified drugs consisted of over-the-counter as well as prescription medications. Furthermore, 117 other medication discrepancies were noted, mainly related to erroneous drug identification and incorrect drug dose. In all, the clinical pharmacists identified 379 (24.2%) medication discrepancies, of which 188 (49.6%) were judged clinically relevant.

CONCLUSIONS

Pharmacist-acquired medication histories enhance the medication reconciliation process, both in patients residing at home and in a nursing home prior to hospitalization. A focus should be placed on seamless care procedures that facilitate the transfer of medication histories between primary and secondary care in both of these populations.

Using explicit criteria to evaluate the quality of prescribing in elderly Italian outpatients: a cohort study

BACKGROUND AND OBJECTIVE

Inappropriate prescribing in the elderly population is a well-recognized problem in public health. The Beers criteria have been widely used to evaluate the quality of prescribing for the elderly. However, because the Beers criteria were developed in the United States, they are not fully applicable in Italy. The purpose of this study was to establish explicit criteria for potentially inappropriate medication prescribing (PIP) for the elderly and assess the prevalence of and factors associated with PIP among elderly residents in the Local Health Unit of Parma, Italy according to the developed criteria.

METHODS

A nine-member expert panel was convened to identify a list of inappropriate medications reflecting the Italian prescribing habits. The panel decided to refine and update the 2002 Beers criteria. Consensus through a Nominal Group Technique was reached to classify the identified 23 inappropriate medications into three categories: 17 medications to be always avoided, three medications rarely appropriate, and three medications with some indications but often misused. A retrospective cohort study using the 2006 Parma Local Health Unit automated outpatient prescriptions database was conducted. The cohort comprised 91 741 elderly individuals >or=65 years with at least one prescription medication. PIP was defined as having a prescription claim for at least one inappropriate medication.

RESULTS AND DISCUSSION

A total of 23 662 elderly in the cohort (25.8%) had at least one PIP. Of these, 14.1% received prescriptions for two medications of concern, and 2.0% for three or more. Using the expert panel's categories, 59.2% of the elderly receiving PIP had prescriptions for drugs that should always be avoided, 33.9% for rarely appropriate drugs, and 19.1% for drugs that have some indications but are often misused. Non-steroidal anti-inflammatory drugs (35.7% of subjects) were the most frequently occurring PIP, followed by ticlopidine (17.6%), doxazosin (15.5%), and amiodarone (13.6%). Female, older age, overall number of drugs prescribed, greater number of chronic conditions were factors associated with greater odds of receiving PIP.

CONCLUSION

Via the developed criteria, the study corroborates that PIP among elderly outpatients is a substantial issue in Parma Local Health Unit, Italy. Knowledge of the prevalence of PIP and associated factors should gear efforts to develop strategies to reduce PIP in outpatient settings in Italy.

Potentially inappropriate medications in the elderly: the PRISCUS list

BACKGROUND

Certain drugs are classified as potentially inappropriate medications (PIM) for the elderly because they carry an increased risk of adverse drug events in this patient group. PIM lists from other countries are of limited usefulness in Germany because different drugs are on the market in each country and prescribing practices vary as well. Thus, a list of potentially inappropriate medications for the elderly was developed specifically for use in Germany.

METHODS

A preliminary PIM list suitable for the German market was created on the basis of a selective literature search and a qualitative analysis of published international PIM lists. The final German PIM list was developed by means of a comprehensive, structured expert survey in two rounds (a so-called Delphi process).

RESULTS

83 drugs in a total of 18 drug classes were rated as potentially inappropriate for elderly patients. For 46 drugs, the experts came to no clear decision after the second Delphi round. For cases in which the administration of a PIM is clinically necessary, the final PRISCUS list contains recommendations for clinical practice, e.g. monitoring of laboratory values and dose adaptation. Therapeutic alternatives are also listed.

CONCLUSION

Potentially inappropriate medications carry the risk of causing adverse drug events in the elderly. A drawback of using a Delphi process to generate a PIM list, as was done for the new German list, is that little scientific evidence is currently available for the evaluation of active substances, potential therapeutic alternatives, and indicated monitoring procedures. Thus, the validity and practicability of the PRISCUS list remain to be demonstrated (and the same holds for PIM lists already published in other countries). It should be used as a component of an overall concept for geriatric pharmacotherapy in which polypharmacy and interacting medications are avoided, and doses are regularly re-evaluated.

Potentially inappropriate medication in elderly hospitalized patients

Balanced and safe prescribing is difficult to achieve in frail older adults with multiple comorbid diseases. This issue is of particular concern, especially in elderly hospitalized patients because hospitalization exposes such individuals to an increased risk of adverse drug reactions (ADRs). The avoidance of medications that are considered to be inappropriate is among the interventions for treatment options in elderly patients. A potentially inappropriate medication (PIM) is a drug in which the risk of an adverse event outweighs its clinical benefit, particularly when there is a safer or more effective alternative therapy for the same condition. Explicit criteria have been developed to identify PIMs and among these, Beers' criteria are the most frequently applied in the literature. However, evidence suggests that such criteria cannot easily be applied to elderly hospitalized people in European countries; approximately 20% of drugs listed in Beers' criteria are rarely prescribed or are not available in Europe, and Beers' listed PIMs are not associated with inhospital mortality, length of hospital stay and/or ADRs in Italian studies. On the contrary, ADRs can contribute to accelerated functional decline in elderly hospitalized patients independently of the use of Beers' listed PIMs. Therefore, we will review the evidence pertaining to the application of Beers' criteria in elderly hospitalized patients, while focusing on Italian studies that have investigated the role of PIMs as potential predictors of negative hospital outcomes. In addition, we will also review the available evidence regarding new European criteria on identifying PIMs, because clinical application in elderly hospitalized Europeans is still under investigation.

Microscopic colitis and Medication Use

BACKGROUND: The incidence of microscopic colitis (MC) is increasing, but its etiology remains unknown. Case reports and limited controlled data suggest that commonly prescribed drugs may be triggers. The aim of this study was to evaluate the prevalence of selected medication use [Proton pump inhibitors (PPIs), HMG-CoA reductase inhibitors (statins), and Selective serotonin reuptake inhibitors (SSRIs)] in patients with MC compared to 'random controls' and 'diarrhea controls.' METHODS: All patients were selected from primary care practices of a university health system during 2002 to 2007. Patients with biopsy proven lymphocytic or collagenous colitis were identified as cases. Diarrhea controls consisted of a 10:1 random sample of patients with chronic diarrhea and normal colon biopsies. Ten random controls were matched to each case on sex and index date (date of biopsy proven diagnosis). Drugs prescribed within the year prior to the index date were collected from the electronic medical record system. RESULTS: 26 cases (median age 68.9 yrs), 259 random, and 259 diarrhea controls were identified. The adjusted ORs for PPI, SSRI, and statin prescription within 12 months of diagnosis of MC between cases and diarrhea controls were 0.28 (0.07-1.07), 0.87 (0.28-2.64), 1.12 (0.34-3.71) respectively. Use of PPI and statins was less common in MC patients than in random controls (p<0.05 for both comparisons). CONCLUSIONS: While prior data suggest that PPIs, statins, and SSRIs may be etiologically related to MC, our study found no increased association with these drugs.

Loss of response after switching from brand name to generic formulations: three cases and a discussion of key clinical considerations when switching

Generic formulations of medications are marketed as therapeutically equivalent and less expensive than branded ones. Multiple studies and case reports have described relapses and worsening clinical outcome in patients after a switch from a brand name to a generic medication. Recent studies have shown that generics do not always lead to the expected costs savings, reducing the impetus to proceed with compulsory generic switching. We report on three patients who experienced clinical deterioration after commencing the generic formulation of their previous brand name psychotropic medication. We discuss key clinical differences between original and generic formulations of the same medication. The use of bioequivalence as an indicator of therapeutic and clinical equivalence, the lack of appropriate studies comparing generic and brand name medications and differences in excipients are some of the factors that could explain variation in clinical response between generic and brand name medications. Generic switching should be decided on a case-by-case basis with disclosure of potential consequences to the patient.