Principles of drug therapy in older patients: rational drug prescribing

Expert consensus recommendations for the management of asthma in older adults

Asthma is a public health problem in patients of any age, although there is still a tendency to erroneously assume that it is almost always confined to children and young people. Epidemiological studies indicate that, from the sixth decade of life, the prevalence of this disease in countries such as Spain reaches 6-10%, with a higher prevalence among women aged 64 to 75 years. In addition, two-thirds of asthma deaths occur at this stage of life, resulting in a substantial number of hospital admissions, longer hospital stays and, from a finance point of view, significant direct economic costs. Asthma in older adults (65 years or older) is now a matter of great concern, the reality of which is underestimated and undertreated. It is therefore essential to establish appropriate recommendations for the diagnosis and treatment of asthma in the aging population. This consensus, which brings together the latest evidence available, was conceived with this objective. The proposed recommendations/conclusions are the result of a nominal consensus developed throughout 2019 and validated by panellists in successive rounds of voting.

Factors influencing trends in opioid prescribing for older people: a scoping review

Aim:

The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people.

Background:

Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group.

Methods:

This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends.

Findings:

A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA.

Conclusions:

A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.

Less Medication Use in Inpatients With Severe Mental Illness Receiving a Multidisciplinary Lifestyle Enhancing Treatment. The MULTI Study III

Besides having an unhealthy lifestyle contributing to premature mortality, inpatients with severe mental illness (SMI) use high dosages of medication. Previous research has shown improved health after lifestyle improvements in SMI. In addition, we aimed to retrospectively study whether a multidisciplinary lifestyle enhancing treatment (MULTI) was associated with changes in medication use after 18 months, as compared with patients that continued treatment as usual (TAU) and explored mediation by a change in physical activity. We conducted an observational study within a cohort of inpatients with SMI, who received MULTI (N = 65) or continued TAU (N = 49). Data on their somatic and psychotropic medications were collected, converted into defined daily dose (DDD), and analyzed using linear multilevel regression, correcting for baseline value and differences between groups in age, diagnosis, and illness severity. Compared with TAU, the DDD for psychotropic medication significantly decreased with MULTI (B = -0.55, P = 0.02). Changes in total activity did not mediate this association, suggesting that multiple components of MULTI contributed. Corrected between-group analyses for subgroups of medication were not possible due to lack of power and skewed distributions. Within-group data showed a decreased proportion of users as well as median DDD in both groups for almost all medications. In addition to previously reported health improvements after 18 months of MULTI, we observed a significant decrease in dose of psychotropic medication in MULTI compared to TAU. This first study evaluating a wide range of medications indicates a possible effect of lifestyle improvements on medication use in inpatients with SMI. Findings need to be confirmed in future controlled studies, however.

Pharmacological reasons that may explain why randomized clinical trials have failed in acute heart failure syndromes

Acute heart failure (AHF) represents a clinical challenge as it encloses a heterogeneous group of syndromes (AHFS) with different pathophysiology, clinical presentations, prognosis and response to therapy. In the last 25years multiple therapeutic targets have been identified and numerous new drugs were evaluated but, up to now, all failed to demonstrate a consistent benefit on clinical outcomes. Moreover, a repeated finding has been the poor correlation between the encouraging results of preclinical and early clinical trials and the lack of effect on outcomes observed in phase III trials. We review several possible pharmacological reasons that may explain the lack of success to develop new drugs and the pharmacological challenges to overcome in the future to develop new more effective and safer drugs for the treatment of AHFS.

National indicators for quality of drug therapy in older persons: the Swedish experience from the first 10 years

Inappropriate drug use is an important health problem in elderly persons. Beginning with the Beers’ criteria in the early 1990s, explicit criteria have been extensively used to measure and improve quality of drug use in older people. This article describes the Swedish indicators for quality of drug therapy in the elderly, introduced in 2004 and updated in 2010. These indicators were designed to be applied to people aged 75 years and over, regardless of residence and other characteristics. The indicators are divided into drug specific, covering choice, indication and dosage of drugs, polypharmacy, drug–drug interactions (DDIs), drug use in decreased renal function and in some symptoms; and diagnosis specific, covering the rational, irrational and hazardous drug use in common disorders in elderly people. During the 10 years since introduction, the Swedish indicators have several applications. They form the basis for recommendations for drug therapy in older people, are implemented in prescribing supports and drug utilisation reviews, are used in national benchmarking of the quality of Swedish healthcare and have contributed to initiatives from pensioner organisations. The indicators have also been used in several pharmacoepidemiological studies. Since 2005, there have been signs of improvement of the quality of drug prescribing to elderly persons in Sweden. For example, the prescribing of drugs that should be avoided in older persons decreased by 36 % between 2006 and 2012 in persons aged 80 years and older. Similarly, drug combinations that may cause DDIs decreased by 26 % and antipsychotics by 41 %. The indicators have likely contributed to this.

Narrow therapeutic index drugs: a clinical pharmacological consideration to flecainide

Purpose

The therapeutic index (TI) is the range of doses at which a medication is effective without unacceptable adverse events. Drugs with a narrow TI (NTIDs) have a narrow window between their effective doses and those at which they produce adverse toxic effects. Generic drugs may be substituted for brand-name drugs provided that they meet the recommended bioequivalence (BE) limits. However, an appropriate range of BE for NTIDs is essential to define due to the potential for ineffectiveness or adverse events. Flecainide is an antiarrhythmic agent that has the potential to be considered an NTID. This review aims to evaluate the literature surrounding guidelines on generic substitution for NTIDs and to evaluate the evidence for flecainide to be considered an NTID.

Methods

A review of recommendations from various regulatory authorities regarding BE and NTIDs, and publications regarding the NTID characteristics of flecainide, was carried out.

Results

Regulatory authorities generally recommend reduced BE limits for NTIDs. Some, but not all, regulatory authorities specify flecainide as an NTID. The literature review demonstrated that flecainide displays NTID characteristics including a steep drug dose–response relationship for safety and efficacy, a need for therapeutic drug monitoring of pharmacokinetic (PK) or pharmacodynamics measures and intra-subject variability in its PK properties.

Conclusions

There is much evidence for flecainide to be considered an NTID based on both preclinical and clinical data. A clear understanding of the potential of proarrhythmic effects or lack of efficacy, careful patient selection and regular monitoring are essential for the safe and rational administration of flecainide.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-015-1832-0) contains supplementary material, which is available to authorized users.

Are interventions recommended by pharmacists during Home Medicines Review evidence-based?

INTRODUCTION

Over the past decade medication review services have been implemented in many countries, including Australia, UK and USA. Although, the attitudes and barriers to the implementation of evidence-based medicine have been investigated, the extent to which medication review recommendations are evidence-based is not known.

OBJECTIVE

To determine (1) the extent to which pharmacist's recommendations during medication review services were consistent with the evidence-based guides at the time of the review; and (2) the nature and extent of drug-related problems (DRPs) and the actions recommended by pharmacists to resolve DRPs.

METHOD

A retrospective review of Home Medicines Review cases performed on 224 community-dwelling older people (65 years or older). The chi-squared test for categorical variables was used to compare the proportion of recommendations that were evidence-based and recommendations for which no evidence could be identified in the most common Australian information sources. DRPs and the actions recommended to resolve the DRPs were classified according to previously employed criteria.

RESULTS

Pharmacists made a total of 1114 therapeutic recommendations to general practitioners, of which 964 required supporting pharmacotherapeutic evidence. The majority (94%) of the pharmacists' recommendations were in accordance with the evidence-based guides, as compared with the recommendations for which no evidence could be identified (P < 0.001). Pharmacists reported that 98% of the patients had at least one problem with use of their medication detected.

CONCLUSION

The majority of the actions recommended by pharmacists during the medication review process were consistent with the literature embedded in key Australian information sources. Medication management in older people is complex and challenging, as highlighted by the DRPs identified in 98% of our patients. A suitably trained pharmacist, with full access to the patient, medical record and supporting resources, can help to improve the quality use of medicines in this at-risk population.

Targeting suboptimal prescribing in the elderly: a review of the impact of pharmacy services

OBJECTIVE

To review the currently available literature on the impact of interventions by pharmacists on suboptimal prescribing in the elderly.

DATA SOURCES

MEDLINE, EMBASE, and International Pharmaceutical Abstracts databases were searched for studies published between January 1992 and December 2008. Key words included medication review, drug regimen review, pharmaceutical services, pharmaceutical care, pharmacists, medications, appropriateness, suboptimal, underuse, aged, elderly, randomized controlled trial, inappropriate, prescribing, and intervention.

STUDY SELECTION AND DATA EXTRACTION

To be included in the review, studies must have been conducted in patients 65 years or older, published in English, randomized and controlled, and must have included an intervention delivered by a pharmacist or had a pharmacist as a member of the intervention team. From each relevant study, the following data were extracted: study duration, country, number of patients, year of publication, objective, type and impact of the intervention, method used to assess suboptimal prescribing, and data concerning the quality of the study.

DATA SYNTHESIS

A total of 38 articles were identified, of which 12 matched our inclusion criteria. Seven articles included interventions initiated by pharmacists, and the remaining 5 described interventions in which the pharmacist was a part of the multidisciplinary team. A broad range of tools was used to measure prescribing appropriateness; we found that a consensus on the best approach has not been reached. Most of the studies involving pharmacists showed significant improvement in suboptimal prescribing at one or more time points. However, most of these interventions were directed toward reducing the overuse or misuse of medications.

CONCLUSIONS

Pharmacy services to reduce suboptimal prescribing have shown promising and noteworthy improvements. More research is needed to address the underutilization of medications in the elderly and healthcare impact of reducing suboptimal prescribing.

Improper renal dosing in long-term care facilities

OBJECTIVES

With advancing age, physiologic changes occur that affect drug metabolism. Possibly the most predictable function decline in geriatric population is renal function.

METHODS

The prescribing habits of physicians and the attention given to patient renal function was investigated. Data was collected from two nursing facilities in southeastern Georgia.

RESULTS

Based on two models of prescribing habits and using logistic regression estimates, we concluded that physicians do not follow recommendations for dose adjustment of renally excreted medications in these two facilities.

CONCLUSION

We recommend that physicians consider evaluating current medications and establishing a base line for renal function and degree of decline.

Physician-patient and pharmacist-patient communication: geriatrics' perceptions and opinions

OBJECTIVE

Earlier research examined the perceptions of the pharmacist-patient relationship quality using data from a systematic random sample of non-institutionalized elderly in the United States. The purposes of this study were to determine: (1) how the findings of this study, conducted in a culturally diverse urban area in Queens, New York, compare with the earlier study; (2) how community-dwelling elderly patients in a metropolitan area perceive their relationship with the pharmacist compared to the physician; and (3) the extent to which their perceived relationship quality predicts medication-related knowledge, medication-related outcomes, and self-efficacy for medication management.

METHODS

One hundred and twenty-one elderly individuals aged 65 and over who took at least one prescription medication, selected from three senior centers, participated in the study. Of the total responses, 102 were useable.

RESULTS

Our sample demonstrated significantly lower levels of perceived quality of relationship with their pharmacist compared to earlier research. In contrast, the participants in this study perceived a better quality of relationship with their physicians than pharmacists. Further, the quality of relationship with physician predicted medication-related knowledge, medication-related outcome expectations, and self-efficacy for medication management.

CONCLUSION

The findings of this study suggest that pharmacists still have a way to go to fully meet patients' healthcare needs, particularly in culturally diverse urban settings.

PRACTICE IMPLICATIONS

Further research is needed to examine ways to improve pharmacist-patient interactions and, therefore, patients' perceptions of pharmacists.

Disease-Modifying Antirheumatic Drug Use in the Elderly Rheumatoid Arthritis Patient

During the 10-year period since the last review was done by Gardner and Furst, studies have furthered the knowledge of the use of disease-modifying antirheumatic drugs (DMARDs) in the elderly rheumatoid arthritis (RA) patient. This article briefly reviews the clinical pharmacology of humans as they age, and details the effects of aging on the specific pharmacokinetics and responses to commonly used DMARDs. There has been some progress in understanding the elderly RA patient; however, data are insufficient to provide much confidence in DMARDs effects in the elderly.

Bariatric Programs in Nursing Homes

The increase in prevalence of obesity in older individuals and the association of obesity with increased morbidity, functional decline, hospitalization, and complications is expected to increase the number of individuals who have obesity requiring nursing home care, particularly subacute and short-term rehabilitation. Providing appropriate nursing home care to residents who have obesity requires environmental modifications, specialized equipment, and staff training. Effective nursing home care of residents who have obesity is interdisciplinary and requires special nursing, medical, nutritional, psychosocial, and rehabilitation considerations.

Disease-modifying antirheumatic drug use in the elderly rheumatoid arthritis patient

During the 10-year period since the last review was done by Gardner and Furst, studies have furthered our knowledge of use of disease-modifying antirheumatic drugs (DMARDs) in the elderly rheumatoid arthritis (RA) patient. This article will briefly review the clinical pharmacology of human as they age, and detail the effects of aging on the specific pharmacokinetics and responses to commonly used DMARDs. There has been some progress in understanding the elderly RA patient, however, there is insufficient data for much confidence in DMARDs effects in the elderly.

Pharmacology of palliative medicine

OBJECTIVE

To describe the concepts of both pharmacokinetics and pharmacodynamics and how it applies to palliative medicine.

DATA SOURCES

Research and review articles and textbooks.

CONCLUSION

Most patients who have an illness that requires palliation are elderly, have co-morbid conditions, and are on many medications. Both age and disease can alter the way drugs are handled by the body (pharmacokinetics) and how they affect the body (pharmacodynamics).

IMPLICATIONS FOR NURSING PRACTICE

The oncology nurse, armed with the correct knowledge about medications, can have an important inmpact on improving the patient's care, safety, and quality of life.

Selected medical management of the older rehabilitative patient 11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

This self-directed learning module highlights present practices of geriatric medicine that are commonly seen in an inpatient rehabilitation setting. It is a part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. In particular, attention is given to update physiatrists in the geriatric medical advances in pharmacotherapeutic considerations, the management of hypertension, diabetes mellitus, urinary tract infections, and sleep disorders.

OVERALL ARTICLE OBJECTIVE

To update the common present-day medical practices for older persons seen in a rehabilitation setting.

Compliance with Dosing Guidelines in Patients with Chronic Kidney Disease

OBJECTIVE

To assess the level of reported compliance with renal dosing guidelines in inpatient, long-term care, and ambulatory settings.

DATA SOURCES

Available databases (MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, ACP Journal Club) were searched (1966-December 2002) to identify published literature pertaining to renal dosing guideline compliance in patients with chronic kidney disease.

STUDY SELECTION AND DATA EXTRACTION

All articles addressing renal dosing guideline compliance in inpatient, long-term care or ambulatory settings were included. Six articles matching our inclusion criteria were reviewed.

DATA SYNTHESIS

Patients with chronic kidney disease require appropriate medication dosing for disease severity and level of renal function for avoiding adverse drug events, preventing additional renal injury, and optimizing patient outcomes. Consensus-based medication dosing guidelines are readily available and provide initial dose estimations, which can be further individualized based on disease severity and therapeutic response. Studies conducted in hospitals found renal dosing guideline noncompliance rates ranged from 19% to 67%. Limited data in long-term care reported a noncompliance rate of 34%. While published studies concerning compliance to renal dosing recommendations in ambulatory settings are not available, an abstract indicated 69% noncompliance.

CONCLUSIONS

Based on limited published data, improvements in renal dosing guideline compliance are needed in all settings where data are available. Research is needed to further assess the appropriateness of renal dosing in ambulatory settings and inform quality improvement efforts in all settings.

Pharmacologic issues in the critically ill

The pharmacotherapy of critically ill patients poses numerous challenges to the ICU team. Polypharmacy and alterations in drug disposition are common in the ICU; critically ill patients have limited physiologic reserve to deal with adverse drug events. Careful prescribing, based upon sound pharmacologic principles, decreases the potential for preventable adverse events and maximizes the opportunity for successful therapy. A systematic approach to reporting, analysis, and prevention of errors is a further step in our ultimate goal to provide optimal care for the vulnerable patients whom we support in our ICUs.