Pharmacy practice, research, education, and advocacy for older adults

Geriatric Pain Protocol: Impact of Multimodal Pain Care for Elderly Orthopaedic Trauma Patients

Hip fractures are costly, and associated complications are the leading cause of injury-related deaths in persons 65 years or older. Pain medications in this population can be more potent, have a longer duration of action, and have serious side effects (Chau et al., 2008). Hip fractures are projected to reach 6.26 million worldwide by 2050 (Gullberg et al., 1997; Kannus et al., 1996). Morrison et al. (2003) report that uncontrolled pain leads to increased hospital length of stay (LOS), delayed physical therapy, and long-term functional impairment. The Geriatric Pain Protocol (GPP) is Cedars-Sinai's multimodal pain management solution, addressing the needs of older adult inpatients who have suffered fractures. Can the implementation of GPP reduce the morphine milligram equivalents (MMEs) used, LOS, and postoperative outcomes compared with non-GPP patients? Study participants included hip fracture patients admitted between February 1, 2019, and March 5, 2021; data were collected prospectively from electronic medical records. Inclusion criteria were patients 65 years or older with a hip fracture sustained from a ground-level fall and surgical candidate. Participants were divided into two categories: Geriatric Fracture Program (GFP) and non-GFP, with physician participation in the GFP being the differentiating factor. End points included postoperative pain, postoperative opioid utilization, LOS, complications, and 30-day readmission rates. The Mann-Whitney U test and Fisher's exact test were used for data analysis. Spearman's rank-based correlation coefficient was used to assess associations. The GPP decreased MME daily totals on Days 1 and 2 and improved pain management compared with non-GPP patients. The MMEs were lower in the GPP group than in the non-GPP group for both Postoperative Day 1 (POD1) (p = .007) and POD2 (p = .043); Numerical Rating Scale (NRS) Pain on POD1 was lower in the GPP group (vs. non-GPP, p = .013). There were no group differences in NRS POD2 Pain or complications (all ps > .1). The study sample (N = 453) had no significant difference between sex and LOS (all ps > .3). Although not statistically significant, the 30-day readmission rate trended lower in patients treated in accordance with the GPP. Use of the multimodal GPP reduced pain levels and MME totals for older adult hip fracture inpatients. More data are needed to evaluate the efficiency of the proposed protocol. Future studies should explore the possibilities of using the GPP across the geriatric orthopaedic patient care continuum.

Cannabis use and sleep: Expectations, outcomes, and the role of age

STUDY OBJECTIVES

Determine relationship between cannabis use with 1) expectations of cannabis being a sleep aid, 2) subjective sleep outcomes, and 3) the influence of age on these relationships.

METHODS

In 152 moderate cannabis users with a wide age range (67% female, mean age = 31.45, SD = 12.96, age range = 21-70; mean days of cannabis use in prior two weeks = 5.54, SD = 5.25) we examined the influence of cannabis use history and behaviors on expectations of cannabis being a sleep aid and sleep outcomes via the Pittsburgh Sleep Quality Index (PSQI). Moderation analysis examined the role of age in the relationship between cannabis use and sleep outcomes.

RESULTS

Endorsing current cannabis use and more days of cannabis use were associated with increased expectations that cannabis use improves sleep (all β > 0.03, p < 0.04). Frequency of recent use and reported average THC or CBD concentration were largely not associated with sleep outcomes. However, endorsing current cannabis use was associated with worse subjective sleep quality (β = 1.34, p = 0.02) and increased frequency of consuming edibles was associated with worse subjective sleep efficiency (β = 0.03, p = 0.04), lower sleep duration (β = 0.03, p = 0.01), and higher global PSQI scores (worse overall sleep) (β = 0.10, p = 0.01). Additionally, age had a moderating influence on the relationship between increased self-reported concentration of CBD and both better sleep duration and sleep quality (both p < 0.03). While the main effects of cannabis use on sleep outcomes did not survive multiple comparisons correction test (all p adj > 0.34), the adjusted p values for the main effects of cannabis behaviors/history on expectations of cannabis as a sleep aid (p adj = 0.07-0.09) and the main effects of CBD concentration on sleep duration (p adj = 0.08), as well as the interaction terms of CBD and age for that model (p adj = 0.07), were trending.

CONCLUSION

Cannabis users have increased expectations of cannabis being a sleep aid, but few associations existed between cannabis use and sleep outcomes. The two exceptions were endorsing any cannabis use and frequency of edible use. Additionally, age may be an important moderator of the potential positive influence CBD concentration can have on sleep.

Developing dementia-friendly pharmacies in Austria: a health promotion approach

The need for integrated, accessible and person-centred care for people with dementia to foster quality of life and facilitate life in the community has been voiced by health policy. Pharmacies have the potential to provide easily accessible information and support for people with dementia, caregivers and the public. The 'Dementia-friendly Pharmacy' programme aimed at re-orienting community pharmacy in Austria, focusing on stronger inclusion of professional counselling into core services. It followed principles of health promotion and person-centred care, aiming at empowering all actors involved, and at fostering quality of life. Methodologically, the programme was based on participatory health research, thus involving all relevant actors and consolidating their perspectives on issues related to dementia care. In the course of the programme, a workshop series covering topics relevant for dementia care in community pharmacy, as well as prototypes for small-scale projects were developed, and measures were taken for securing sustainability. Findings related to programme development and implementation encompass pharmacy staff's motivation to participate in the programme, counselling knowledge and skills development, experience with building community partnerships and cross-organizational development and sustainability. Furthermore, effectiveness of the programme has been established. These findings are discussed against the background of re-orienting pharmacies.

Medication review versus usual care to improve drug therapies in older inpatients not admitted to geriatric wards: a quasi-experimental study (RASP-IGCT)

Background

Interdisciplinary geriatric consultation teams (IGCT) are regularly requested to provide comprehensive geriatric assessments in older inpatients. Our primary aim was to evaluate whether medication reviews increased the number of IGCT-provided drug-related recommendations. Secondary aims were to reduce the number of potentially inappropriate medications (PIMs), and to identify the acceptance rate of and determinants for the number of recommendations.

Methods

A before-after study was performed in older inpatients not admitted to acute geriatric wards. The before cohort received usual care (UC); the after cohort was subjected to the intervention (I), consisting of a systematic medication review, based on but not limited to the RASP (Rationalization of Home Medication by an Adjusted STOPP in Older Patients) list. The primary outcome measure was the number of IGCT-provided drug-related recommendations. Age, sex, Charlson Comorbidity Index, creatinine clearance and serum creatinine were ascertained upon enrolment. Following variables were determined on admission and at discharge: number of drugs and number as well as type of RASP-identified PIMs. Acceptance by ward-based physicians was also determined. Poisson regression was performed to identify determinants for the primary outcome measure.

Results

Fifty-nine participants were enrolled (n_UC = 29; n_I = 30). The intervention increased the number of drug-related recommendations from a median of 0 (IQR: 0–1) to 8 (IQR: 6.75–10) (p < 0.001). The median number of accepted recommendations differed significantly as well (UC vs. I: 0.0 (0.0–0.5) vs. 3.0 (0.0–5.3); p < 0.001). In the intervention cohort, patients were discharged with fewer drugs compared to admission (UC vs. I: 108.5%, IQR: 100.0–135.8% vs. 92%, IQR: 80.5–103.5%; p = 0.002). More RASP PIMs were discontinued in the intervention cohort, with a mean difference of 1.49 RASP PIMs (95% confidence interval (CI): 0.70, 2.23; p < 0.001). Regression analysis identified two determinants: allocation to the intervention cohort with an incidence rate ratio (IRR) of 14.1 (95% CI: 8.30, 23.8) and the number of preadmission drugs with an IRR of 1.06 (95% CI: 1.03, 1.09).

Conclusions

A structured medication review as part of usual IGCT care may contribute to an increased detection of drug-related problems and help to further reduce polypharmacy in older inpatients, not admitted to acute geriatric care wards.

Trial registration

NCT02165618, retrospectively registered June 17, 2014.

Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial

STUDY OBJECTIVE

We compare the analgesic efficacy and safety of subdissociative intravenous-dose ketamine (SDK) versus morphine in geriatric Emergency Department (ED) patients.

METHODS

This was a prospective, randomized, double-blind trial evaluating ED patients aged 65 and older experiencing moderate to severe acute abdominal, flank, musculoskeletal, or malignant pain. Patients were randomized to receive SDK at 0.3 mg/kg or morphine at 0.1 mg/kg by short intravenous infusion over 15 min. Evaluations occurred at 15, 30, 60, 90, and 120 min. Primary outcome was reduction in pain at 30 min. Secondary outcomes included overall rates of adverse effects and incidence of rescue analgesia.

RESULTS

Thirty patients per group were enrolled in the study. The primary change in mean pain scores was not significantly different in the ketamine and morphine groups: 9.0 versus 8.4 at baseline (mean difference 0.6; 95% CI -0.30 to 1.43) and 4.2 versus 4.4 at 30 min (mean difference -0.2; 95% CI -1.93 to1.46). Patients in the SDK group reported higher rates of psychoperceptual adverse effects at 15, 30, and 60 min post drug administration. Two patients in the ketamine group and one in the morphine group experienced brief desaturation episodes. There were no statistically significant differences with respect to changes in vital signs and need for rescue medication.

CONCLUSION

SDK administered at 0.3 mg/kg over 15 min provides analgesic efficacy comparable to morphine for short-term treatment of acute pain in the geriatric ED patients but results in higher rates of psychoperceptual adverse effects. ClinicalTrials.gov Registration #: NCT02673372.

Initial titration with 200 μg fentanyl buccal tablets: a retrospective safety analysis in Korean cancer patients

BACKGROUND/AIMS

Managing breakthrough pain (BTP) is important for many cancer patients because of the rapid onset and unpredictable nature of the pain episodes. Fentanyl buccal tablets (FBTs) are a rapid-onset opioid indicated for BTP management. However, FBT titration is needed to optimize BTP management. In this study, we aimed to evaluate the safety and efficacy of initiating 200 μg FBTs in Korean cancer patients.

METHODS

A retrospective analysis of medical records was performed on all advanced cancer patients treated with FBTs for BTP between October 2014 and July 2015. Patients who received initial doses of 200 μg FBTs for at least 3 days and cases in which FBT was available at doses of 200, 400, and 800 μg were included.

RESULTS

A total of 56 patients with a median age of 62 years (range, 32 to 80) were analyzed, 61% of whom were male. The median and mean values of morphine equivalent daily doses were 60 mg/day (range, 15 to 540) and 114.8 ± 124.8 mg/day, respectively. The most frequent effective doses of FBT were 200 μg (41 patients, 74%) and 400 μg (12 patients, 21%). Three patients (5%) could not tolerate 200 μg of FBT and discontinued treatment. Nausea, vomiting, somnolence, and dizziness were the most frequent treatment-related adverse events (AEs), and all AEs were grade 1 (mild) or 2 (moderate).

CONCLUSIONS

FBT at the initial 200 μg dosage was well-tolerated and effective as a BTP management strategy in Korean cancer patients. Further prospective studies are needed to determine appropriate initiating doses of FBT in Korean patients with opioid tolerance.

[Opioids for noncancer pain in the elderly]

BACKGROUND

Opioids are increasingly used in the elderly. Side effects differ compared to other analgesics.

PURPOSE

In this review article, special aspects about using opioids for noncancer pain in older people and in geriatric patients are identified.

CURRENT SITUATION

So far randomized controlled trials for the indication of and comparison between various opioids have been performed in middle-aged patients and not exclusively in geriatric patients or elderly (> 75 years). Furthermore, the evidence for multimorbid elderly patients with respect to side effects is also very poor.

RECOMMENDATIONS

The indication for opioid therapy should be narrow. The patient and their caregivers must be provided patient information regarding opioid therapy. The principle "start low, go slow" is highly recommended. To reduce the risk of falls, longer acting opioids should be used and short acting opioids should be avoided. Everyday relevant negative effects on cognition are possible in opioid use and have to be observed. As recommended in the recently published German guideline for long-term use of opioids in noncancer pain a critical check after 3 months and in case of dosing over 120 mg morphine equivalents is advisable, especially for older patients. Liver and kidney function and drug interactions have to be taken into consideration like in every age group.

What Do We Know about Opioids and the Kidney?

Evidence suggests a link between opioid use and kidney disease. This review summarizes the known renal manifestations of opioid use including its role in acute and chronic kidney injury. Both the direct and indirect effects of the drug, and the context which leads to the development of renal failure, are explored. While commonly used safely for pain control and anesthesia in those with kidney disease, the concerns with respect to side effects and toxicity of opioids are addressed. This is especially relevant with the worldwide increase in the use of opioids for medical and recreational use.

Safety, pharmacodynamics, and pharmacokinetics of multiple oral doses of delta-9-tetrahydrocannabinol in older persons with dementia

RATIONALE

Data on safety, pharmacodynamics, and pharmacokinetics of tetrahydrocannabinol (THC) are lacking in dementia patients.

METHODS

In this randomized, double-blind, placebo-controlled, crossover trial, we evaluated the safety, pharmacodynamics, and pharmacokinetics of THC in ten patients with dementia (mean age 77.3 ± 5.6). For 12 weeks, participants randomly received oral THC (weeks 1-6, 0.75 mg; weeks 7-12, 1.5 mg) or placebo twice daily for 3 days, separated by a 4-day washout period.

RESULTS

Only 6 of the 98 reported adverse events were related to THC. Visual analog scale (VAS) feeling high, VAS external perception, body sway-eyes-open, and diastolic blood pressure were not significantly different with THC. After the 0.75-mg dose, VAS internal perception (0.025 units; 95% CI 0.010-0.040) and heart rate (2 beats/min; 95% CI 0.4-3.8) increased significantly. Body sway-eyes-closed increased only after 1.5 mg (0.59°/s; 95% CI 0.13-1.06). Systolic blood pressure changed significantly after both doses of THC (0.75 mg, -7 mmHg, 95% CI -11.4, -3.0; 1.5 mg, 5 mmHg, 95% CI 1.0-9.2). The median T max was 1-2 h, with THC pharmacokinetics increasing linearly with increasing dose, with wide interindividual variability (CV% up to 140%). The mean C max (ng/mL) after the first dose (0-6 h) was 0.41 (0.18-0.90) for the 0.75-mg dose and 1.01 (0.53-1.92) for the 1.5-mg dose. After the second dose (6-24 h), the C max was 0.50 (0.27-0.92) and 0.98 (0.46-2.06), respectively.

CONCLUSIONS

THC was rapidly absorbed and had dose-linear pharmacokinetics with considerable interindividual variation. Pharmacodynamic effects, including adverse events, were minor. Further studies are warranted to evaluate the pharmacodynamics and efficacy of higher THC doses in older persons with dementia.

Geriatric pharmacology and pharmacotherapy education for health professionals and students: a systematic review

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

The rate of medication errors is high, and these errors can cause adverse drug reactions. Elderly individuals are most vulnerable to adverse drug reactions. One cause of medication errors is the lack of drug knowledge on the part of different health professionals. Medical curricula have changed in recent years, resulting in less education in the basic sciences, such as pharmacology.

WHAT THIS STUDY ADDS

Our study shows that little curricular time is devoted to geriatric pharmacology and that educational programmes in geriatric pharmacology have not been thoroughly evaluated. While interest in pharmacology education has increased recently, this is not the case for geriatric pharmacology education. Education on geriatric pharmacology should have more attention in the curricula of health professionals, given the often complex pharmacotherapy in elderly patients. Educational topics should be related to the known risk factors of medication errors, such as polypharmacy, dose adjustments in organ dysfunction and psychopharmacotherapeutics.

AIMS

Given the reported high rates of medication errors, especially in elderly patients, we hypothesized that current curricula do not devote enough time to the teaching of geriatric pharmacology. This review explores the quantity and nature of geriatric pharmacology education in undergraduate and postgraduate curricula for health professionals.

METHODS

Pubmed, Embase and PsycINFO databases were searched (from 1 January 2000 to 11 January 2011), using the terms 'pharmacology' and 'education' in combination. Articles describing content or evaluation of pharmacology education for health professionals were included. Education in general and geriatric pharmacology was compared.

RESULTS

Articles on general pharmacology education (252) and geriatric pharmacology education (39) were included. The number of publications on education in general pharmacology, but not geriatric pharmacology, has increased over the last 10 years. Articles on undergraduate and postgraduate education for 12 different health disciplines were identified. A median of 24 h (from 15 min to 4956 h) devoted to pharmacology education and 2 h (1-935 h) devoted to geriatric pharmacology were reported. Of the articles on education in geriatric pharmacology, 61.5% evaluated the teaching provided, mostly student satisfaction with the course. The strength of findings was low. Similar educational interventions were not identified, and evaluation studies were not replicated.

CONCLUSIONS

Recently, interest in pharmacology education has increased, possibly because of the high rate of medication errors and the recognized importance of evidence-based medical education. Nevertheless, courses on geriatric pharmacology have not been evaluated thoroughly and none can be recommended for use in training programmes. Suggestions for improvements in education in general and geriatric pharmacology are given.

Silos to systems: three models for developing geriatric interprofessional education

OBJECTIVE

To describe three interprofessional education (IPE) programs in geriatrics and to encourage senior care pharmacists' innovation and participation in IPE teaching.

DESIGN

Description of three geriatric IPE programs showing how pharmacy faculty along with colleagues in other health professions established, conducted, and evaluated their respective IPE programs.

SETTING

Schools of pharmacy and their affiliated interprofessional geriatric clerkship sites. PROGRAM DESCRIPTION AND MAIN OUTCOME MEASUREMENTS: Reported are program histories, participating health professions, teaching objectives, program designs and operations, outcomes, funding sources, challenges and barriers encountered, and strategies to overcome problems. Learning activities to enable students to achieve competencies recommended by the Institute of Medicine and the Partnership for Health in Aging are described for each of the three IPE programs.

RESULTS

All three programs provide learning activities that help students achieve core interprofessional competencies. The two programs in which students, with preceptor supervision, have provided direct patient care services have long histories, despite challenges and barriers. The third program has established curriculum plans that will be implemented upon resolution of challenges.

CONCLUSION

Successful geriatric IPE programs can be established and conducted in various practice settings. Program sustainability requires participation and interaction of faculty, site preceptors, and students of multiple health professions; administrative and funding support of collaborating partners; and a curriculum that fosters teamwork, shared responsibilities, and joint decision-making while delivering patient-centered care. Senior care pharmacists need to be proactive partners in establishing and conducting IPE in geriatrics.

The added challenges of bone metastases treatment in elderly patients

Most cancers occur in those older than the age of 65 years. As the population of the world ages and life expectancies continue to increase, it is important to address treatment challenges for elderly patients. This narrative review details the challenges of palliative radiotherapy treatment for elderly patients with bone metastases. We begin with the definition of elderly and its appropriateness, outlining recent demographic data of patients with cancer. The current status of elderly participation in clinical trials is discussed by reviewing the recent literature and clinical trial data. Factors affecting enrolment of the elderly are assessed, with a focus on palliative radiotherapy trials, and what we can do to improve accrual in this data-driven setting. At present, there is a lack of level 1 evidence that evaluates the optimal treatment for elderly patients with bone metastases. Therefore, a review of safety and efficacy is given based on previously published reports. Palliative radiotherapy for elderly patients is a worthwhile treatment and should be recommended regardless of age, as supported by available evidence. Patient, family and physician concerns about physical burden may be reduced as single treatments (that often can be done in a single visit) are as beneficial as multiple treatments for painful bone metastases. In elderly patients, radiotherapy may even be the best treatment for these cases as opioid-related adverse events are amplified in this group and often dosages are more difficult to titrate. Clinicians should continue to encourage the enrolment of elderly patients on to clinical trials as these data form the basis of optimal treatment guidelines. Radiation oncologists are encouraged to reduce the physical burden for elderly patients by offering single treatments where appropriate and completing consultation, treatment simulation and treatment in a single clinical visit.

Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes

OBJECTIVE

The objective of this study was to assess implementation of a pharmaceutical care model for the multidisciplinary care of elderly patients in nursing homes.

SETTING

Prospective study, medication review, from January 2007 to December 2009 in ten nursing homes affiliated to the Pharmacie interjurassienne (PIJ), Switzerland.

METHOD

Medication use data were collected and reviewed by a pharmacist, focusing on drug indication, dosing, side effects, renal/hepatic elimination and interactions. Drug-related problems (DRPs) were discussed face-to-face with the responsible physician and a nurse. The pharmaceutical care issues were formulated and medication interventions proposed during this meeting. DRPs and interventions were documented using the Pharmaceutical Care Network Europe scheme version 5.00 (PCNE V5.00). The economic impact of the service was estimated through a retrospective evaluation of annual drug costs. A satisfaction evaluation was conducted among practitioners and nurses.

MAIN OUTCOME MEASURES

DRPs, interventions, treatment changes implemented.

RESULTS

Drug therapy of 329 patients was reviewed. The number of medicines per patient ranged from 2 to 27 (mean 12.8). A total of 1,225 DRPs were detected and discussed with the physician and the nurse. Medication review led to 343 medical evaluations secondary to drug-drug interactions and 803 treatment adaptations: 373 drugs were stopped, 197 dosages changed, 95 instructions for use amended, 86 drug choices were altered, 35 drug formulations changed and 17 new drugs started. According to the Anatomical Classification System, the main classes involved in interventions were related to Alimentary tract and metabolism (n = 285), Nervous system (n = 189) and Cardiovascular system (n = 115). Since the outset of the PIJ, the annual drug costs decreased in nursing homes with medication review including a pharmacist, whereas it was stable in the other nursing homes. The satisfaction evaluation showed a very positive appreciation by practitioners and nurses.

CONCLUSION

The study showed an efficient pharmaceutical care model, well accepted by physicians and nurses. It also indicated that for elderly patients, continuous drug review contributed to improved drug therapy, reduced unnecessary polypharmacy and reduced pharmaceutical costs.

Pharmacist Approach to Geriatrics

Pharmacists have traditionally focused on the appropriate use of medications to enhance the functional status of the elderly patient. However, in the proper provision of pharmaceutical care, the influence of lifestyle factors on the use and misuse of medications cannot be ignored. The pharmacist collaborates with other members of the health care team to ensure that drugs are dosed according to known changes occurring with age such as pharmacokinetic and pharmacodynamic alterations. Also, medications that may decrease cognitive function, impair gait/balance, or reduce sensory stimulation must be avoided. The appropriate use of medications can improve the functional status and reduce morbidity in the elderly patient, and drug adherence issues should be addressed to ensure that the elderly patient can receive the optimal benefit from his or her medication regimen. Pharmacists, in collaboration with physicians and other health care providers, can help to ensure that a comprehensive approach to patient care occurs, one that involves medications, diet, and exercise as it embraces the mind, body, and spirit.

Disparate inclusion of older adults in clinical trials: priorities and opportunities for policy and practice change

Older adults are vastly underrepresented in clinical trials in spite of shouldering a disproportionate burden of disease and consumption of prescription drugs and therapies, restricting treatments' generalizability, efficacy, and safety. Eliminating Disparities in Clinical Trials, a national initiative comprising a stakeholder network of researchers, community advocates, policymakers, and federal representatives, undertook a critical analysis of older adults' structural barriers to clinical trial participation. We present practice and policy change recommendations emerging from this process and their rationale, which spanned multiple themes: (1) decision making with cognitively impaired patients; (2) pharmacokinetic differences and physiological age; (3) health literacy, communication, and aging; (4) geriatric training; (5) federal monitoring and accountability; (6) clinical trial costs; and (7) cumulative effects of aging and ethnicity.

Mitigation of medication mishaps via medication therapy management

BACKGROUND

In 2006, the Center for Medicare & Medicaid Services incorporated the requirement for a Medication Therapy Management Program (MTMP) for individuals with Part D coverage to ensure that drug regimens provide optimal therapeutic outcomes through improved medication use, thereby reducing adverse drug events.

OBJECTIVE

To evaluate the effectiveness of an MTMP implemented for Medicare Advantage Prescription Drug members enrolled with Health Alliance Plan (HAP) during 2006 and 2007.

METHODS

Patient eligibility for MTMP was searched electronically. Clinical pharmacists researched medication histories and adherence and, through telephone contact, ascertained the patients' healthcare goals and needs. A patient-centered pharmacotherapy plan was created and implemented collaboratively with the patient's physician(s). To ensure that therapy goals were met, pharmacists performed follow-up interventions. Clinical outcomes and cost savings were compared for MTMP enrollees versus those declining enrollment.

RESULTS

Average enrollment rate for the MTMP was 20% for 2006 and 2007. Nearly 60% of interventions involved changing therapy to improve efficacy and greater than 40% involved changing therapy to improve safety. Analysis of 2006 data revealed an overall improvement in electronically measurable clinical outcomes for MTMP enrollees versus individuals who declined enrollment, including a trend toward improved adherence to drug therapy for heart failure, insulin use, and a significant reduction in gastrointestinal bleeds (p = 0.001). Cost-savings analysis indicated a greater reduction in total prescription per member per month costs ($PMPM) of 17.2% for MTMP enrollees versus a 7% reduction for those who declined MTMP (p = 0.001). Patients who enrolled into the 2006 MTMP also saw a sustained positive effect in lowered $PMPM for prescription drugs in 2007.

CONCLUSIONS

The HAP MTMP, conducted through telephone contacts, produced positive trends in improving clinical outcomes, reductions in pharmacy costs, and sustained pharmacy cost savings for patients who enrolled in the MTMP compared with patients who declined enrollment.

Opiates and elderly: use and side effects

The evaluation of pain and the subsequent issue of pain control is a clinical challenge that all healthcare providers face. Pain in the elderly population is especially difficult given the myriad of physiological, pharmacological, and psychological aspects of caring for the geriatric patient. Opiates are the mainstay of pain treatment throughout all age groups but special attention must be paid to the efficacy and side effects of these powerful drugs when prescribing to a population with impaired metabolism, excretion and physical reserve. In a random chart review of 300 US veterans, 44% of those receiving an analgesic also received opioids. The increasing use of opiates for pain management by healthcare practitioners requires that those prescribing opioids be aware of the special considerations for treating the elderly. This article will address the precautions one must take when using opiates in the geriatric population, as well as the side effects and ways to minimize them.

Polymedicine and aging. Enhancing older adult care through advanced practitioners. GNPs and elder care pharmacists can help provide optimal pharmaceutical care

Approximately one third of all drugs prescribed in the United States are considered unnecessary. Polymedicine, polypharmacy, medication nonadherence, and adverse drug reactions are among the top five causes of acute care hospitalizations in persons older than age 65. These conditions significantly increase health care costs and will continue to do so at an alarming rate as America's population ages. Although medications are an important factor in improving and maintaining the quality of life for older adults, polymedicine places them at risk of an acute care admission for medication-related problems and other complications. This article reviews polymedicine and common medication errors, explores the depth of the problem in aging clients, and advocates for the use of gerontological nurse practitioners as advanced practice nurses and specialty-trained elder care pharmacists as active members of the interdisciplinary health care team.

Geriatric pharmacy education: a strategic plan for the future

The aging of the US population will have a major effect on the future practice of pharmacy. By 2030, 20% of Americans will be aged 65 years and older, an increase from 12.4% in 2000. A challenge to colleges and schools of pharmacy in the 21st century is to prepare students and practitioners to meet the growing pharmaceutical care needs of the older adult population and to meet these needs in a variety of care settings. This paper reviews the present state of geriatric pharmacy education and training, including strategies for ensuring that practicing pharmacists will have adequate knowledge, skills, attitudes, and values to provide this care. Secondly, this report provides strategic directions and recommendations for successfully implementing geriatrics curricula at an institutional level.

Geriatric content in pharmacotherapy and therapeutics textbooks

OBJECTIVES

To determine the extent to which therapeutics textbooks address age-related medication information.

METHODS

Criteria for 5 disease states prevalent among geriatric patients were developed based on the content of a geriatric textbook and from expert reviewers' input. The criteria were used to determine the degree to which geriatric content was addressed in 3 therapeutics textbooks.

RESULTS

The therapeutics textbooks contained less than half of the critical points for 3 disease states: chronic obstructive pulmonary disease, heart failure, and diabetes mellitus (31%, 33%, and 46%, respectively). In addition, the textbooks addressed only one half to two thirds of the criteria for the remaining 2 disease states of osteoarthritis and dementia (55% and 68%, respectively). Criteria specific to the elderly were addressed less often than criteria that were important but not unique to the elderly (38% and 63%, respectively).

CONCLUSIONS

Current therapeutics textbooks have significant gaps in geriatric medication information. Users of these textbooks must supplement them with primary literature or a geriatric textbook for more comprehensive medication therapy management information.