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Blaszczyk AT, Mathys M, Le J. A Review of Therapeutics for Treatment-Resistant Depression in the Older Adult. Drugs Aging 2023; 40:785-813. [PMID: 37596380 DOI: 10.1007/s40266-023-01051-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/20/2023]
Abstract
One-third of older adults with depression meet criteria for treatment resistance, typically defined as a lack of response to two or more adequate trials of an antidepressant. Treatment resistance contributes to an unfavorable prognosis, compromised medical outcomes, heightened disability, accelerated cognitive decline, and an elevated risk of developing dementia. Despite this significant morbidity, evidence is sparse for how to proceed with treatment in this population. Non-pharmacologic therapy (e.g., diet, psychotherapy) can be utilized as adjunctive therapy, despite little published evidence of benefit, given that the risks are low. Pharmacotherapy trials in the treatment-resistant late-life depression population lack strong methods and external validity; however, the use of venlafaxine as monotherapy and add-on therapy, as well as lithium, bupropion, or aripiprazole as add-on therapy to standard antidepressant therapy, have enough evidence that a trial with appropriate monitoring is a prudent strategy. Electroconvulsive therapy remains a well-studied safe therapy, especially when used as maintenance treatment once an initial cycle is completed but is traditionally underutilized in the treatment-resistant late-life depression population. Ensuring non-pharmacologic and pharmacologic strategies are optimized and given a sufficient trial in those with treatment-resistant late-life depression is the best we can do for this vulnerable population.
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Affiliation(s)
- Amie Taggart Blaszczyk
- Department of Pharmacy Practice, Texas Tech University HSC School of Pharmacy-Dallas/Fort Worth, 5920 Forest Park Rd, Dallas, TX, USA.
| | - Monica Mathys
- Department of Pharmacy Practice, Texas Tech University HSC School of Pharmacy-Dallas/Fort Worth, 5920 Forest Park Rd, Dallas, TX, USA
| | - Jennifer Le
- Harrison College of Pharmacy, Auburn University, Auburn, AL, USA
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Blaszczyk AT, Sandlin K, Mirza S, Hernandez L, Bader H, Hall RG. Potential for Drug Interactions and Polypharmacy from Treatment of COVID-19 in Long-term Care. J Am Med Dir Assoc 2022; 23:949-950. [PMID: 35504327 PMCID: PMC8983604 DOI: 10.1016/j.jamda.2022.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/04/2022]
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Blaszczyk AT, Bailey TA, Tapia S. ABH Gel: Comforting Cure or Pricey Placebo? J Am Med Dir Assoc 2020; 22:23-27. [PMID: 33246839 DOI: 10.1016/j.jamda.2020.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/29/2020] [Accepted: 10/04/2020] [Indexed: 12/23/2022]
Abstract
Despite a lack of evidence of benefit, the compounded product ABH gel (lorazepam, diphenhydramine, and haloperidol) continues to be prescribed for individuals in hospice and palliative care settings for the treatment of nausea and vomiting and terminal delirium. More effective and reliable pharmacological and nonpharmacological strategies exist for the treatment of these conditions in the palliative care and hospice settings. We discuss the pharmacokinetic and clinical evidence for the individual components of ABH gel, as well as the compounded product, and attempt to understand the mechanism of effect that some purport to see, as well as why the compound continues to enjoy such a cult following. Truly, the continued use of ABH gel makes for a pricey placebo and delays the treatment of end-of-life symptoms with modalities that work.
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Affiliation(s)
- Amie Taggart Blaszczyk
- Division of Geriatrics, Department of Pharmacy Practice, Texas Tech University Health Sciences Center School of Pharmacy, Dallas, TX, USA.
| | - Trista Askins Bailey
- Division of Geriatrics, Department of Pharmacy Practice, Texas Tech University Health Sciences Center School of Pharmacy, Abilene, TX, USA
| | - Shannon Tapia
- Rocky Mountain Senior Care, Golden, CO, USA; Brighton Hospice, Denver, CO, USA
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Moreno V, Nguyen CL, Blaszczyk AT. The Importance of a Complete Allergy Assessment in Clinical Stewardship. Sr Care Pharm 2019; 34:510-513. [PMID: 31462354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
National agencies have championed stewardship initiatives to enhance antimicrobial and opioid use in long-term care facilities. Health care providers for these residents have been given the task to ensure "the right drug is used for the right indication at the right time and duration." One potential challenge to this is incorrect or incomplete documentation of allergies. Many long-term care facilities have traditionally, and currently, used a "list format" of allergies in, or on, the resident's chart. This approach is incomplete as it rarely provides detailed information about the reaction to a particular drug. Senior care pharmacists and their students can play a role within long-term care facilities by helping ensure the optimal selection of drugs by providing a detailed allergy assessment that documents detailed reaction information, whenever possible.
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Moreno V, Nguyen CL, Blaszczyk AT. The Importance of a Complete Allergy Assessment in Clinical Stewardship. Sr Care Pharm 2019. [DOI: 10.4140/tcp.n.2019.510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
National agencies have championed stewardship initiatives to enhance antimicrobial and opioid use in long-term care facilities. Health care providers for these residents have been given the task to ensure "the right drug is used for the right indication at the right time and duration."
One potential challenge to this is incorrect or incomplete documentation of allergies. Many long-term care facilities have traditionally, and currently, used a "list format" of allergies in, or on, the resident's chart. This approach is incomplete as it rarely provides detailed information
about the reaction to a particular drug. Senior care pharmacists and their students can play a role within long-term care facilities by helping ensure the optimal selection of drugs by providing a detailed allergy assessment that documents detailed reaction information, whenever possible.
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McCarrell JL, Bailey TA, Duncan NA, Covington LP, Clifford KM, Hall RG, Blaszczyk AT. A review of citalopram dose restrictions in the treatment of neuropsychiatric disorders in older adults. Ment Health Clin 2019; 9:280-286. [PMID: 31293848 PMCID: PMC6607952 DOI: 10.9740/mhc.2019.07.280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction Neuropsychiatric disorders affect millions of older adults. Despite this, there are relatively few older adults included in clinical trials evaluating treatments for psychiatric disorders. Citalopram has been evaluated in older adults with neuropsychiatric disorders and has largely been found beneficial, making the 2011 US Food and Drug Administration (FDA) safety advisory on citalopram extremely impactful. Methods A literature search was completed using the PubMed database. Results were limited to clinical trials conducted in older adults that were published in English. Results Review of the literature confirms the efficacy of citalopram in depression, anxiety, depression associated with Parkinson disease, and behavioral and psychological symptoms of dementia. Additionally, no adverse cardiac outcomes have been described related to citalopram. Discussion The FDA's evidence for applying this safety advisory to citalopram is minimal and largely based on surrogate markers, such as the QTc interval rather than clinical and safety outcomes. Citalopram is known to increase the QTc, but this increase has not been linked to adverse cardiac outcomes. The evidence for efficacy and against adverse outcomes suggests that a reevaluation of the dosing restrictions in older adults with neuropsychiatric disorders is needed.
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Blaszczyk AT, Mang BH, Garza H, Mathys M. The Impact of Cholinesterase Inhibitors with or without Memantine on Antipsychotic Prescribing. Consult Pharm 2018; 33:273-282. [PMID: 29789049 DOI: 10.4140/tcp.n.2018.273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Background Alzheimer's disease (AD) medications have been suggested to positively affect behavior, though not universally in all studies. Their impact on antipsychotic use is not well-defined. Methods This cross-sectional, retrospective study evaluated residents with AD on cholinesterase inhibitors, memantine, both, or neither throughout multiple long-term care facilities during July 2014. Patients were included if they: were between 65 and 89 years of age, had a diagnosis of AD, and had a cognitive assessment within three months of the study period. Patients residing in the facility for 100 days or fewer, or those having a Centers for Medicare & Medicaid Services-approved diagnosis for antipsychotic use were excluded. The primary outcome was the prevalence of antipsychotic prescribing in patients receiving AD medications compared with those without AD therapy. The Texas Tech University Health Sciences Center institutional review board approved the study protocol. Results Of 1,282 patients screened, 285 (161 AD medications and 124 no-AD medications) were analyzed. Median cognitive status scores suggested severe cognitive impairment. Patients receiving AD medications had higher antipsychotic utilization compared with those without AD medications (27% vs. 19%, respectively; P = 0.08). Patients receiving combination AD medications had the highest antipsychotic use. No statistically significant differences were detected in cognitive status subgroups. Of interest is that a post-hoc analysis found a statistically significant association with greater antipsychotic use and increasing number of AD medications. Conclusion Long-term care facility residents with AD receiving AD medications had higher rates of antipsychotic use compared with those not receiving AD treatment. The link between antipsychotic use and the number of AD medications may point to overprescribing in dementia with behavioral disturbances as a potential contributing factor.
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Blaszczyk AT, Mang BH, Garza H, Mathys M. The Impact of Cholinesterase Inhibitors with or without Memantine on Antipsychotic Prescribing. ACTA ACUST UNITED AC 2018. [DOI: 10.4140/tcp.n.2018.273.] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Blaszczyk AT, Mahan RJ, McCarrell J, Sleeper RB. Using a Polypharmacy Simulation Exercise to Increase Empathy in Pharmacy Students. Am J Pharm Educ 2018; 82:6238. [PMID: 29692437 PMCID: PMC5909869 DOI: 10.5688/ajpe6238] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 04/24/2017] [Indexed: 05/22/2023]
Abstract
Objective. To assess whether the Jellybean Polypharmacy Simulation Exercise (JPSE) improved empathy in pharmacy students. Methods. The JPSE was given to all third-professional year pharmacy students in a required Special Populations course with pre- and post-scores on the Kiersma-Chen Empathy Scale (KCES) assessed, and open-ended questions on lessons learned from the exercise. Results. Pharmacy students showed a statistically significant increase in KCES scores after completing the JPSE. Open-ended question responses reflected personal growth and appreciation for patients managing difficult medication regimens. Conclusion. This polypharmacy simulation showed the ability to increase empathy in pharmacy students, as well as mimic a realistic experience in managing a multi-drug, multi-dose medication regimen.
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Affiliation(s)
- Amie Taggart Blaszczyk
- Texas Tech University Health Sciences Center School of Pharmacy – Dallas/Fort Worth, Texas
| | - Rebecca J. Mahan
- Texas Tech University Health Sciences Center School of Pharmacy – Abilene, Texas
| | - Jamie McCarrell
- Texas Tech University Health Sciences Center School of Pharmacy – Amarillo, Texas
| | - Rebecca B. Sleeper
- Texas Tech University Health Sciences Center School of Pharmacy – Lubbock, Texas
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Chintapenta M, Spence J, Kwon HI, Blaszczyk AT. A Brief Review of Caprylidene (Axona) and Coconut Oil as Alternative Fuels in the Fight Against Alzheimer's Disease. ACTA ACUST UNITED AC 2017; 32:748-751. [DOI: 10.4140/tcp.n.2017.748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Monica Chintapenta
- Texas Tech University Health Sciences Center School of Pharmacy – Dallas/Fort Worth, Dallas, Texas, USA
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Affiliation(s)
- Justin Spence
- Texas Tech University Health Sciences Center School of Pharmacy-Dallas/Fort Worth, Dallas, Texas, USA
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Abstract
The mandate of the Centers for Medicare & Medicaid Services to decrease the use of antipsychotics in long-term care facilities requires creative solutions. Low-dose quetiapine is used for a multitude of behavioral disorders and sleep problems in the nursing facility population. Yet, at doses of 25 mg per day or less, it doesn't have strong affinity (if any) for the dopamine-2 (D2) receptor, but it does maintain affinity for the histamine-1 and alpha-1 receptors. This begs the question: If it's not antagonizing the D2 receptor, could the use of something with similar receptor-affinity produce the same result, allowing discontinuation of the antipsychotic altogether? Using knowledge of receptor affinities and the pharmacologic action of low-dose quetiapine, consultant pharmacists may have one additional tool in their armamentarium of fighting inappropriate antipsychotic use.
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Affiliation(s)
- Amie Taggart Blaszczyk
- Geriatrics, Texas Tech University Health Sciences Center-Dallas/Fort Worth, Dallas, Texas, USA
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Abstract
Consultant pharmacists improve the lives of older adults by providing medication management, avoiding adverse drug reactions, and uncovering duplicative therapy. Despite this, there is a lack of legislation supporting the role of the consultant pharmacist in many of the settings-other than nursing facilities-where seniors reside. Specifically, federal and state laws do not recognize consultant pharmacists for their specialized role in pharmacotherapy and the potential benefits they bring to older adults in assisted living facilities. Among many services, consultant pharmacists may provide monthly medication reviews, staff medication education, and medication system management in assisted living facilities. A literature search was conducted to identify literature supporting the benefits of consultant pharmacists in assisted living facilities. Gaps in available literature are discussed as are ideas for expanding the role of consultant pharmacists in assisted living facilities.
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Affiliation(s)
- Eva Coulson
- Texas Tech University Health Sciences Center School of Pharmacy, Dallas/Fort Worth, Dallas, Texas, USA
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Hall RG, Blaszczyk AT, Thompson KA, Brouse SD, Giuliano CA, Frei CR, Forcade NA, Mortensen EM, Bell T, Bedimo RJ, Alvarez CA. Impact of empiric weight-based vancomycin dosing on nephrotoxicity and mortality in geriatric patients with methicillin-resistant Staphylococcus aureus bacteraemia. J Clin Pharm Ther 2014; 39:653-7. [PMID: 25200273 DOI: 10.1111/jcpt.12203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/12/2014] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Few studies have evaluated the effect of vancomycin dosing on the health outcomes in geriatric patients. Data are needed to determine whether higher vancomycin dosing strategies are more effective in geriatric patients and/or lead to excessive rates of adverse events. METHODS This study used a subset of patients aged ≥65 years from a multicentre, retrospective, cohort study of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. Patients received ≥ 48 h of empiric vancomycin between 1 July 2002 and 30 June 2008. We compared the incidence of nephrotoxicity and in-hospital mortality in patients who received guideline-recommended dosing (at least 15 mg/kg/dose) to patients who received lower dosing. Multivariable generalized mixed-effect models were constructed to determine independent risk factors for nephrotoxicity and in-hospital mortality. RESULTS AND DISCUSSION Half of the cohort (46% of 92 patients) received guideline-recommended dosing. Empiric use of weight-based dosing did increase the percentage of patients achieving a vancomycin trough ≥ 15 mg/L (57% vs. 42%). Nephrotoxicity occurred in 32% of patients and 26% died during their hospitalization. Guideline-recommended dosing was not associated with significant changes in nephrotoxicity (OR 1·13; 95% CI 0·40-3·19) or in-hospital mortality (OR 1·14; 95% CI 0·41-3·18) in the multivariable analysis. WHAT IS NEW AND CONCLUSION In this study of geriatric patients, guideline-recommended dosing was not associated with significant changes in nephrotoxicity or mortality. As 40% of the patients who received guideline-recommended dosing failed to achieve a target vancomycin trough of ≥ 15 mg/L, future studies should focus on dosing strategies to increase target attainment rate.
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Affiliation(s)
- R G Hall
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, Dallas, TX, USA; Department of Clinical Sciences, University of Texas Southwestern, Dallas, TX, USA
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Abstract
PURPOSE The purpose of this study was to investigate if patients of nonwhite race are less likely to receive insulin therapy for treatment of poorly controlled diabetes than patients of white race. METHODS A retrospective review was performed of patients with an A1C >10%. The primary objective was to determine any difference in the initiation of insulin between white and nonwhite patients. Secondary outcomes measured the impact of clinic type and provider specialty on the initiation of insulin therapy. Exclusion criteria included those patients with type 1 diabetes mellitus, those who were previously receiving insulin, and those without an outpatient clinic visit within 14 days of an A1C >10%. RESULTS A total of 277 patients were included. Of these patients, 132 (47.7%) were white, followed by 95 (34.2%) black non-Hispanic patients and 30 (10.8%) Hispanic/Latino patients. No difference was found in receipt of insulin therapy for nonwhite patients as compared to white patients (12.5 vs 21.4, P = .117). Neither clinic type nor provider specialty impacted initiation of insulin therapy. No changes to medication regimen were made at 35% of clinic visits. CONCLUSIONS Failure to intensify diabetic medications was common in this outpatient setting. There were no disparities in the receipt of insulin therapy between white and nonwhite patients.
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Affiliation(s)
- Katura C Bullock
- Texas Tech University Health Sciences Center School of Pharmacy, Department of Pharmacy Practice; Veterans Affairs North Texas Health
Care System (VANTHCS), Dallas, Texas (Dr Bullock, Dr Edwards, Dr Greene, Dr Shah, Dr Blaszczyk)
| | - Krystal L Edwards
- Texas Tech University Health Sciences Center School of Pharmacy, Department of Pharmacy Practice; Veterans Affairs North Texas Health
Care System (VANTHCS), Dallas, Texas (Dr Bullock, Dr Edwards, Dr Greene, Dr Shah, Dr Blaszczyk)
| | - Ronald Shane Greene
- Texas Tech University Health Sciences Center School of Pharmacy, Department of Pharmacy Practice; Veterans Affairs North Texas Health
Care System (VANTHCS), Dallas, Texas (Dr Bullock, Dr Edwards, Dr Greene, Dr Shah, Dr Blaszczyk)
| | - Sachin R Shah
- Texas Tech University Health Sciences Center School of Pharmacy, Department of Pharmacy Practice; Veterans Affairs North Texas Health
Care System (VANTHCS), Dallas, Texas (Dr Bullock, Dr Edwards, Dr Greene, Dr Shah, Dr Blaszczyk)
| | - Amie Taggart Blaszczyk
- Texas Tech University Health Sciences Center School of Pharmacy, Department of Pharmacy Practice; Veterans Affairs North Texas Health
Care System (VANTHCS), Dallas, Texas (Dr Bullock, Dr Edwards, Dr Greene, Dr Shah, Dr Blaszczyk)
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Mathys ML, McCarrell J, Sleeper RB, Blaszczyk AT. Visual hallucinations treated with the reinitiation of memantine in a patient with Lewy body dementia. Ann Pharmacother 2013; 47:e10. [PMID: 23386073 DOI: 10.1345/aph.1r522] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report on a patient with Lewy body dementia who developed worsening of hallucinations with memantine withdrawal and significant improvement with reinitiation of the drug. CASE SUMMARY A 78-year-old man presented to a geriatric psychiatry clinic in March 2011. The patient had experienced gradual memory loss since 2007 and was diagnosed with dementia with Lewy bodies (DLB) in 2009. His medication regimen included donepezil and memantine; his cognitive and functional status appeared stable. Occasional mild visual hallucinations occurred but were not concerning to the patient or his wife. The patient did well to July 2011, when memantine became restricted within the health care institution; memantine was therefore tapered to discontinuation. From July to September 2011, the patient's cognition and function appeared to decline significantly. He also began experiencing severe visual hallucinations daily. Memantine was reinitiated in September 2011 and, within days, the patient was free of hallucinations. By November 2011, his cognition and function were noted to have improved to previous status, and hallucinations were rare. DISCUSSION Three small randomized studies and 4 case reports were found addressing the use of memantine for DLB. Both improvement and worsening of hallucinations were noted with memantine use in the case reports, but the studies showed only a small benefit in cognition. However, cognitive and psychiatric symptoms worsened when memantine was discontinued. One study found that Neuropsychiatric-Inventory scores and hallucination scores improved significantly for patients taking memantine. CONCLUSIONS The literature investigating the use of memantine for the psychiatric symptoms of DLB is limited but there are data noting results similar to what we observed in our patient when his memantine was discontinued and reinitiated.
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Affiliation(s)
- Monica L Mathys
- School of Pharmacy, Texas Tech University Health Sciences Center, Dallas, TX, USA.
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Abstract
HIV infections are a growing concern in the elderly as a result of improvements in therapeutics and monitoring, which have extended the life span for this HIV-infected population. Elderly patients potentially are more complicated to treat than younger HIV-infected individuals because of comorbidities and the physiological effects of aging on pharmacokinetics and pharmacodynamics. The patient, a 67-year-old African-American HIV-infected male, presents to the transitional care unit of university-affiliated hospital refusing to take medications and undergo laboratory testing, including blood draws. This patient's treatment is further complicated by poor renal function, medications with potential interactions, and a recent diagnosis of depression. This case demonstrates treatment and monitoring of an elderly patient with HIV and reveals the complications associated with this disease state. Specifically, it identifies nonadherence to medications and a lack of laboratory results, which affect the efficacy of treatment and monitoring, medication adjustments based on metabolism and renal excretion, monitoring of adverse effects of HIV and antiretroviral therapy, and comorbid conditions that may be linked to HIV and antiretroviral therapy such as depression and bone disease. Education on HIV medications, monitoring, and standards of care for pharmacists working with the geriatric population is warranted and should be emphasized as the HIV-infected elderly population continues to grow.
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Vouri SM, Alvarez CA, Blaszczyk AT. Effects of oral bisphosphonate therapy on serum calcium in elderly veterans with poor kidney function. Am J Geriatr Pharmacother 2012; 10:178-84. [PMID: 22542895 DOI: 10.1016/j.amjopharm.2012.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 03/16/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Limited data exist on the use of bisphosphonates in patients with poor kidney function due to a contraindication derived from inadequate experience among patients with kidney failure, accounting for as much as 25% of nonprescribing when otherwise appropriate. OBJECTIVES To determine whether bisphosphonate use in patients with decreased renal function, as outlined in the package insert (estimated creatinine clearance [eCrCl] <35 mL/min), would result in higher rates of hypocalcemia, as suggested in previous studies. METHODS This was a retrospective cohort study of elderly veterans 65 years of age and older at the Veterans Affairs North Texas Health Care System in Dallas, Texas. We identified 3089 patients who started oral bisphosphonate therapy between August 1, 2003 and July 12, 2010. Of the 252 patients meeting the inclusion criteria, 25 and 227 patients had an eCrCl <35 mL/min and eCrCl ≥35 mL/min, respectively. Analyses of changes in serum calcium from baseline to the 1-year study end point were performed within and between each renal function group. RESULTS Among the veterans with an eCrCl <35 mL/min and eCrCl ≥35 mL/min, there were decreases in median serum calcium levels from baseline to study end point from 9.8 mg/dL (interquartile range [IQR], 9.4-10.2 mg/dL) to 9.3 mg/dL (IQR, 9.0-10.0 mg/dL; P = 0.028) and 9.6 mg/dL (IQR, 9.3-9.9 mg/dL) to 9.4 mg/dL (IQR, 9.1-9.8 mg/dL; P < 0.001), respectively. However, there was no difference in Δcalcium: -0.2 mg/dL (IQR, 0-0.6 mg/dL) and 0.2 mg/dL (IQR, -0.2 to 0.5 mg/dL; P = 0.547), respectively. CONCLUSIONS This exploratory assessment may suggest that, in elderly veterans, the initiation of oral bisphosphonate therapy contributed to a statistically significant decrease in serum calcium levels regardless of baseline renal function; however, the clinical impact of this change does not appear to be significant. Future studies should assess serum calcium in a larger population of patients to confirm the safety of oral bisphosphonates in poor kidney function.
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