Pub Date : 2011-10-01DOI: 10.1016/j.amjopharm.2011.07.002
S. James Matthews RPh, PharmD , Jason W. Lancaster PharmD, BCPS
Background
Urinary tract infections (UTIs) are a common problem in the elderly population. The spectrum of disease varies from a relatively benign cystitis to potentially life-threatening pyelonephritis.
Objective
This review covers the management of asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, antibiotic resistance, catheter-associated bacteriuria/symptomatic UTIs, and antibiotic prophylaxis for recurrent infections in elderly men and women.
Methods
Literature was obtained from English-language searches of MEDLINE (1966–April 2011), Cochrane Library, BIOSIS (1993–April 2011), and EMBASE (1970–April 2011). Further publications were identified from citations of resulting articles. Search terms included, but were not limited to, urinary tract infections, asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, antibiotic resistance, catheter associated urinary tract infections, recurrent urinary tract infections, and elderly.
Results
The prevalence of UTIs in elderly women depends on the location in which these women are living. For elderly women living in the community, UTIs compromise the second most common infection, whereas in residents of long-term care facilities (LTCFs) and hospitalized subjects, it is the number one cause of infection. The spectrum of patient presentation varies from classic signs and symptoms in the independent elderly population to atypical presentations, including increased lethargy, delirium, blunted fever response, and anorexia. Although there are few guidelines specifically directed toward the management of UTIs in the elderly population, therapy generally mirrors the recommendations for the younger adult age groups. When choosing a treatment regimen, special attention must be given to the severity of illness, living conditions, existing comorbidities, presence of external devices, local antibiotic resistance patterns, and the ability of the patient to comply with therapy.
Conclusions
Improved guidelines for the diagnosis and management of UTIs in the elderly population are needed. Better techniques to evaluate and prevent catheter-associated bacteriuria and UTIs await improved diagnostic modalities and catheter technologies. Alternative methods for prophylaxis of patients who suffer from recurrent infections must be found while minimizing the risk of developing or propagating antibiotic resistance.
{"title":"Urinary Tract Infections in the Elderly Population","authors":"S. James Matthews RPh, PharmD , Jason W. Lancaster PharmD, BCPS","doi":"10.1016/j.amjopharm.2011.07.002","DOIUrl":"10.1016/j.amjopharm.2011.07.002","url":null,"abstract":"<div><h3>Background</h3><p><span>Urinary tract infections (UTIs) are a common problem in the elderly population. The spectrum of disease varies from a relatively benign </span>cystitis<span> to potentially life-threatening pyelonephritis.</span></p></div><div><h3>Objective</h3><p><span>This review covers the management of asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, </span>antibiotic resistance<span><span>, catheter-associated bacteriuria/symptomatic UTIs, and antibiotic prophylaxis for </span>recurrent infections in elderly men and women.</span></p></div><div><h3>Methods</h3><p>Literature was obtained from English-language searches of MEDLINE (1966–April 2011), Cochrane Library, BIOSIS (1993–April 2011), and EMBASE (1970–April 2011). Further publications were identified from citations of resulting articles. Search terms included, but were not limited to, <span><em>urinary tract infections, </em><em>asymptomatic bacteriuria</em><em>, acute uncomplicated cystitis</em></span>, <em>acute uncomplicated pyelonephritis, antibiotic resistance, catheter associated urinary tract infections, recurrent urinary tract infections</em>, and <em>elderly</em>.</p></div><div><h3>Results</h3><p>The prevalence of UTIs in elderly women depends on the location in which these women are living. For elderly women living in the community, UTIs compromise the second most common infection, whereas in residents of long-term care facilities (LTCFs) and hospitalized subjects, it is the number one cause of infection. The spectrum of patient presentation varies from classic signs and symptoms<span> in the independent elderly population to atypical presentations, including increased lethargy, delirium, blunted fever response, and anorexia. Although there are few guidelines specifically directed toward the management of UTIs in the elderly population, therapy generally mirrors the recommendations for the younger adult age groups. When choosing a treatment regimen, special attention must be given to the severity of illness, living conditions, existing comorbidities, presence of external devices, local antibiotic resistance patterns, and the ability of the patient to comply with therapy.</span></p></div><div><h3>Conclusions</h3><p>Improved guidelines for the diagnosis and management of UTIs in the elderly population are needed. Better techniques to evaluate and prevent catheter-associated bacteriuria and UTIs await improved diagnostic modalities and catheter technologies. Alternative methods for prophylaxis of patients who suffer from recurrent infections must be found while minimizing the risk of developing or propagating antibiotic resistance.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"9 5","pages":"Pages 286-309"},"PeriodicalIF":0.0,"publicationDate":"2011-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.07.002","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30075530","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-10-01DOI: 10.1016/j.amjopharm.2011.09.003
Jonathan T. Stewart MD
Background
Valproic acid is associated with a variety of hematologic abnormalities, most commonly thrombocytopenia. Pancytopenia is much less common and potentially much more serious. Little is known about the natural course of valproate-induced pancytopenia.
Case summary
We present a patient who developed pancytopenia while taking valproic acid for bipolar illness. After failing to respond to several other mood stabilizers, valproic acid was cautiously reintroduced with close hematologic monitoring. The pancytopenia has not recurred in the past 6 months.
Conclusions
Pancytopenia may not represent an absolute contraindication to continuing valproate therapy, although caution is warranted.
{"title":"Successful Reintroduction of Valproic Acid After the Occurrence of Pancytopenia","authors":"Jonathan T. Stewart MD","doi":"10.1016/j.amjopharm.2011.09.003","DOIUrl":"10.1016/j.amjopharm.2011.09.003","url":null,"abstract":"<div><h3>Background</h3><p><span>Valproic acid<span> is associated with a variety of hematologic abnormalities, most commonly thrombocytopenia. </span></span>Pancytopenia is much less common and potentially much more serious. Little is known about the natural course of valproate-induced pancytopenia.</p></div><div><h3>Case summary</h3><p><span>We present a patient who developed pancytopenia while taking valproic acid for bipolar illness. After failing to respond to several other </span>mood stabilizers, valproic acid was cautiously reintroduced with close hematologic monitoring. The pancytopenia has not recurred in the past 6 months.</p></div><div><h3>Conclusions</h3><p>Pancytopenia may not represent an absolute contraindication to continuing valproate therapy, although caution is warranted.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"9 5","pages":"Pages 351-353"},"PeriodicalIF":0.0,"publicationDate":"2011-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.09.003","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30033862","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-10-01DOI: 10.1016/j.amjopharm.2011.08.004
Daniel Mansour PharmD , Remy Wong MD , Michael Kuskowski PhD , Maurice Dysken MD
Background
Dementia treatment guidelines are not consistent in determining how long to continue acetylcholinesterase inhibitor (AChEI) treatment in patients with Alzheimer's disease.
Objective
Our aim was to examine reasons for AChEI discontinuation in a nursing home to better understand how practitioners actually decide when to stop treatment.
Methods
A retrospective chart review was done on 107 deceased nursing home veterans who had been taking an AChEI to determine the time between discontinuation and death.
Results
In the majority of residents (n = 67; 63%), the AChEI was continued into the week preceding death. Reasons for discontinuation were dying or death (n = 56; 52%), admission to hospice (n = 13; 12.2%), and admission to the nursing home (n = 5; 4.7%). Admission to hospice (P = 0.01), hospice length of stay (P = 0.0004), and length of stay at Minnesota Veterans Home (P = 0.02) were significantly associated with discontinuation of AchEI before the last week of life.
Conclusion
Our study showed that residents were significantly more likely to have their AChEI discontinued if they were either admitted to hospice, stayed longer in hospice, or stayed longer in the nursing home. In addition, the majority of residents continued AChEI treatment until sometime during the week before death occurred.
{"title":"Discontinuation of Acetylcholinesterase Inhibitor Treatment in the Nursing Home","authors":"Daniel Mansour PharmD , Remy Wong MD , Michael Kuskowski PhD , Maurice Dysken MD","doi":"10.1016/j.amjopharm.2011.08.004","DOIUrl":"10.1016/j.amjopharm.2011.08.004","url":null,"abstract":"<div><h3>Background</h3><p><span>Dementia treatment guidelines are not consistent in determining how long to continue </span>acetylcholinesterase inhibitor<span><span> (AChEI) treatment in patients with </span>Alzheimer's disease.</span></p></div><div><h3>Objective</h3><p>Our aim was to examine reasons for AChEI discontinuation in a nursing home to better understand how practitioners actually decide when to stop treatment.</p></div><div><h3>Methods</h3><p>A retrospective chart review was done on 107 deceased nursing home veterans who had been taking an AChEI to determine the time between discontinuation and death.</p></div><div><h3>Results</h3><p>In the majority of residents (n = 67; 63%), the AChEI was continued into the week preceding death. Reasons for discontinuation were dying or death (n = 56; 52%), admission to hospice (n = 13; 12.2%), and admission to the nursing home (n = 5; 4.7%). Admission to hospice (<em>P</em> = 0.01), hospice length of stay (<em>P</em> = 0.0004), and length of stay at Minnesota Veterans Home (<em>P</em> = 0.02) were significantly associated with discontinuation of AchEI before the last week of life.</p></div><div><h3>Conclusion</h3><p>Our study showed that residents were significantly more likely to have their AChEI discontinued if they were either admitted to hospice, stayed longer in hospice, or stayed longer in the nursing home. In addition, the majority of residents continued AChEI treatment until sometime during the week before death occurred.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"9 5","pages":"Pages 345-350"},"PeriodicalIF":0.0,"publicationDate":"2011-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.08.004","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30147559","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-10-01DOI: 10.1016/j.amjopharm.2011.08.001
Leticia R. Moczygemba PharmD, PhD , Jamie C. Barner PhD , Kenneth A. Lawson PhD , Carolyn M. Brown PhD , Evelyn R. Gabrillo PharmD , Paul Godley PharmD , Michael Johnsrud PhD
Background
The Medicare Modernization Act of 2003 mandated the provision of medication therapy management (MTM) to eligible Part D beneficiaries to improve medication-related outcomes. As MTM programs evolve, evaluation is necessary to help inform MTM best practices.
Objective
The objective of this study was to determine the impact of pharmacist-provided telephone MTM on: (1) medication and health-related problems (MHRPs); (2) medication adherence; and (3) Part D drug costs.
Methods
This quasi-experimental study included Part D beneficiaries from a Texas health plan. Andersen's Behavioral Model of Health Services Use served as the study framework. MTM utilization was the health behavior. Age, gender, and race were predisposing factors, and number of medications, chronic diseases, and medication regimen complexity were need factors. Outcomes were pre-to-post changes in: (1) MHRPs; (2) medication adherence, using the medication possession ratio (MPR); and (3) total drug costs. Multiple regression was used to analyze group differences while controlling for predisposing and need factors.
Results
At baseline, the intervention (n = 60) and control (n = 60) groups were not statistically different regarding predisposing and need factors, with the exception of gender. The intervention group had significantly (P = 0.009) more men compared with the control group (51.7% vs 28.3%). There were 4.8 (2.7) and 9.2 (2.9) MHRPs identified at baseline and 2.5 (2.0) and 7.9 (3.0) MHRPs remained at the 6-month follow up in the intervention and control groups, respectively. The intervention group (vs control) had significantly more MHRPs resolved (P = 0.0003). There were no significant predictors of change in MPR or total drug costs from baseline to follow up, although total drug costs decreased by $158 in the intervention group compared with a $118 increase in the control group.
Conclusions
A telephone MTM program resolved significantly more MHRPs compared with a control group, but there were no significant changes in adherence and total drug costs.
{"title":"Impact of Telephone Medication Therapy Management on Medication and Health-Related Problems, Medication Adherence, and Medicare Part D Drug Costs: A 6-Month Follow Up","authors":"Leticia R. Moczygemba PharmD, PhD , Jamie C. Barner PhD , Kenneth A. Lawson PhD , Carolyn M. Brown PhD , Evelyn R. Gabrillo PharmD , Paul Godley PharmD , Michael Johnsrud PhD","doi":"10.1016/j.amjopharm.2011.08.001","DOIUrl":"10.1016/j.amjopharm.2011.08.001","url":null,"abstract":"<div><h3>Background</h3><p>The Medicare Modernization Act of 2003 mandated the provision of medication therapy management (MTM) to eligible Part D beneficiaries to improve medication-related outcomes. As MTM programs evolve, evaluation is necessary to help inform MTM best practices.</p></div><div><h3>Objective</h3><p>The objective of this study was to determine the impact of pharmacist-provided telephone MTM on: (1) medication and health-related problems (MHRPs); (2) medication adherence; and (3) Part D drug costs.</p></div><div><h3>Methods</h3><p>This quasi-experimental study included Part D beneficiaries from a Texas health plan. Andersen's Behavioral Model of Health Services Use served as the study framework. MTM utilization was the health behavior. Age, gender, and race were predisposing factors, and number of medications, chronic diseases, and medication regimen complexity were need factors. Outcomes were pre-to-post changes in: (1) MHRPs; (2) medication adherence, using the medication possession ratio (MPR); and (3) total drug costs. Multiple regression was used to analyze group differences while controlling for predisposing and need factors.</p></div><div><h3>Results</h3><p>At baseline, the intervention (n = 60) and control (n = 60) groups were not statistically different regarding predisposing and need factors, with the exception of gender. The intervention group had significantly (<em>P</em> = 0.009) more men compared with the control group (51.7% vs 28.3%). There were 4.8 (2.7) and 9.2 (2.9) MHRPs identified at baseline and 2.5 (2.0) and 7.9 (3.0) MHRPs remained at the 6-month follow up in the intervention and control groups, respectively. The intervention group (vs control) had significantly more MHRPs resolved (<em>P</em> = 0.0003). There were no significant predictors of change in MPR or total drug costs from baseline to follow up, although total drug costs decreased by $158 in the intervention group compared with a $118 increase in the control group.</p></div><div><h3>Conclusions</h3><p>A telephone MTM program resolved significantly more MHRPs compared with a control group, but there were no significant changes in adherence and total drug costs.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"9 5","pages":"Pages 328-338"},"PeriodicalIF":0.0,"publicationDate":"2011-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.08.001","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"29952078","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-10-01DOI: 10.1016/j.amjopharm.2011.07.004
Michelle A. Fravel PharmD, BCPS , Michael E. Ernst PharmD, BCPS
Background
Gout affects 3 million people in the United States, with rates almost 5 times higher in those aged 70 to 79 years compared with those aged <50 years. Management of gout in elderly subjects can be complicated by comorbidities and polypharmacy.
Objective
The purpose of this article was to review the unique clinical presentation, treatment, and prevention of gout in the older adult, with attention to the age-related factors that may affect outcomes in this population.
Methods
PubMed and the Iowa Drug Information Service were searched (1944–January 14, 2011) for clinical studies of gout using the following search terms: gout, elderly, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid, prednisone, prednisolone, methylprednisolone, triamcinolone, allopurinol, febuxostat, probenecid, sulfinpyrazone, uricosuric, fenofibrate, and losartan. Articles were limited to clinical trials in humans, published in English. Citations of these articles were analyzed for additional relevant studies, and current guidelines were also consulted.
Results
Twenty-nine citations were reviewed. Evidence suggests that colchicine, NSAIDs, and corticosteroids are all efficacious in the treatment of acute gout in the older adult. Relevant limitations to colchicine use in the older adult include high cost, dosing restrictions in severe renal and hepatic dysfunction, gastrointestinal intolerance, and potential drug interactions. NSAID therapy is not recommended in older patients with congestive heart failure, renal failure, or gastrointestinal problems. Corticosteroids pose little risk when used in the short-term and may be preferred in patients with contraindications to colchicine or NSAIDs. Urate lowering with allopurinol for prevention of gout is well tolerated and has minimal cost per month; however, dose reduction is recommended in patients with renal impairment, which often results in failure to achieve target serum urate concentrations. Febuxostat does not require dose adjustment in mild to moderate renal disease and may be preferred in older people with this condition.
Conclusion
Management of gout in the older adult involves careful selection of treatment based on potential benefits and consequences of therapy, considered in tandem with individual patient-specific characteristics. ClinicalTrials.gov identifiers NCT00549549
背景:在美国，有300万人患有糖尿病，70至79岁人群的发病率几乎是50岁人群的5倍。老年患者痛风的管理可能因合并症和多种药物而复杂化。目的:本文的目的是回顾老年人痛风的独特临床表现、治疗和预防，并关注可能影响该人群预后的年龄相关因素。方法检索spubmed和爱荷华药物信息服务中心(Iowa Drug Information Service)(1944 - 2011年1月14日)关于痛风的临床研究，检索词为:痛风、老年人、秋水仙碱、非甾体抗炎药(NSAIDs)、皮质类固醇、强的松、强的松龙、甲基强的松龙、曲安奈德、别嘌呤醇、非布司他、probenecid、磺胺吡嗪、尿尿酸、非诺贝特和氯沙坦。文章仅限于用英文发表的人体临床试验。对这些文章的引用进行了分析，以获得更多相关研究，并参考了现行指南。结果共查阅文献29篇。有证据表明秋水仙碱、非甾体抗炎药和皮质类固醇对老年人急性痛风均有效。秋水仙碱在老年人中使用的相关限制包括高成本、严重肾功能和肝功能障碍的剂量限制、胃肠道不耐受和潜在的药物相互作用。非甾体抗炎药不推荐用于有充血性心力衰竭、肾功能衰竭或胃肠道问题的老年患者。皮质类固醇在短期使用时风险很小，可能优先用于秋水仙碱或非甾体抗炎药的禁忌症患者。别嘌呤醇用于预防痛风的尿酸降低耐受性良好，每月成本最低;然而，对于肾功能受损的患者，建议减少剂量，这通常导致无法达到血清尿酸盐的目标浓度。轻至中度肾病患者不需要调整非布司他的剂量，可能更适合患有这种疾病的老年人。结论:老年人痛风的管理需要根据治疗的潜在益处和后果仔细选择治疗方法，并结合患者的个体特征进行考虑。ClinicalTrials.gov标识符NCT00549549、NCT01101035、NCT00241839、NCT01157936、NCT00997542、NCT00288158和NCT00987415。
{"title":"Management of Gout in the Older Adult","authors":"Michelle A. Fravel PharmD, BCPS , Michael E. Ernst PharmD, BCPS","doi":"10.1016/j.amjopharm.2011.07.004","DOIUrl":"10.1016/j.amjopharm.2011.07.004","url":null,"abstract":"<div><h3>Background</h3><p>Gout affects 3 million people in the United States, with rates almost 5 times higher in those aged 70 to 79 years compared with those aged <50 years. Management of gout in elderly subjects can be complicated by comorbidities and polypharmacy.</p></div><div><h3>Objective</h3><p>The purpose of this article was to review the unique clinical presentation, treatment, and prevention of gout in the older adult, with attention to the age-related factors that may affect outcomes in this population.</p></div><div><h3>Methods</h3><p>PubMed and the Iowa Drug Information Service were searched (1944–January 14, 2011) for clinical studies of gout using the following search terms: <span><span><span><span><em>gout, elderly, </em><em>colchicine</em><em>, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid, </em></span><em>prednisone</em><span><em>, </em><em>prednisolone</em><span><em>, </em><em>methylprednisolone</em><span><span><em>, </em><em>triamcinolone</em><span><em>, </em><em>allopurinol</em><em>, </em></span></span><em>febuxostat</em><span><em>, </em><em>probenecid</em><em>, </em></span></span></span></span></span><em>sulfinpyrazone</em><em>, </em></span><em>uricosuric</em><span><em>, </em><em>fenofibrate</em></span></span>, and <span><em>losartan</em></span><span>. Articles were limited to clinical trials in humans, published in English. Citations of these articles were analyzed for additional relevant studies, and current guidelines were also consulted.</span></p></div><div><h3>Results</h3><p><span><span><span><span><span>Twenty-nine citations were reviewed. Evidence suggests that colchicine, NSAIDs, and corticosteroids are all efficacious in the treatment of acute gout in the older adult. Relevant limitations to colchicine use in the older adult include high cost, dosing restrictions in severe renal and hepatic dysfunction, gastrointestinal intolerance, and potential drug interactions. NSAID therapy is not recommended in older patients with congestive heart failure, renal failure, or </span>gastrointestinal problems. Corticosteroids pose little risk when used in the short-term and may be preferred </span>in patients with contraindications to colchicine or NSAIDs. </span>Urate lowering with allopurinol for prevention of gout is well tolerated and has minimal cost per month; however, </span>dose reduction is recommended in patients with renal impairment, which often results in failure to achieve target serum urate concentrations. Febuxostat does not require dose adjustment in mild to moderate </span>renal disease and may be preferred in older people with this condition.</p></div><div><h3>Conclusion</h3><p>Management of gout in the older adult involves careful selection of treatment based on potential benefits and consequences of therapy, considered in tandem with individual patient-specific characteristics. <span>ClinicalTrials.gov</span><svg><path></path></svg> identifiers <span>NCT00549549</span><svg><path></path>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"9 5","pages":"Pages 271-285"},"PeriodicalIF":0.0,"publicationDate":"2011-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.07.004","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30084145","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-10-01DOI: 10.1016/j.amjopharm.2011.08.002
Carri Casteel PhD , Susan J. Blalock PhD , Stefanie Ferreri PharmD , Mary T. Roth PharmD , Karen B. Demby PhD
Background
Falls are the leading cause of fatal and nonfatal unintentional injury among older adults in the United States. Multifaceted falls prevention programs, which have been reported to reduce the risk for falls among older adults, usually include a medication review and modification component. Based on a literature search, no randomized trials that have examined the effectiveness of this component have been published.
Objective
The aim of this article was to report on a retrospective process evaluation of data from a randomized, controlled trial conducted to examine the effectiveness of a medication review intervention, delivered through community pharmacies, on the rate of falls among community-dwelling older adults.
Methods
Patients were recruited through 32 pharmacies in North Carolina. Participants were community-dwelling older adults at high risk for falls based on age (≥65 years), number of concurrent medications (≥4), and medication classes (emphasis on CNS-active agents). The process evaluation measured the recruitment of patients into the study, the process through which the intervention was delivered, the extent to which patients implemented the recommendations for intervention, and the acceptance of pharmacists' recommendations by prescribing physicians.
Results
Of the 7793 patients contacted for study participation, 981 (12.6%) responded to the initial inquiry. A total of 801 (81.7%) participated in an eligibility interview, of whom 342 (42.7%) were eligible. Baseline data collection was completed in 186 of eligible patients (54.4%), who were randomly assigned to the intervention group (n = 93) or the control group (n = 93). Pharmacists delivered a medication review to 73 of the patients (78.5%) in the intervention group, with 41 recommendations for changes in medication, of which 10 (24.4%) were implemented. Of the 31 prescribing physicians contacted with pharmacists' recommendations, 14 (45.2%) responded, and 10 (32.3%) authorized the changes.
Conclusions
Based on the findings from the present study, coordination of care between community pharmacists and prescribers needs to be improved for the realization of potential beneficial effects of medication management on falls prevention.
{"title":"Implementation of a Community Pharmacy–Based Falls Prevention Program","authors":"Carri Casteel PhD , Susan J. Blalock PhD , Stefanie Ferreri PharmD , Mary T. Roth PharmD , Karen B. Demby PhD","doi":"10.1016/j.amjopharm.2011.08.002","DOIUrl":"10.1016/j.amjopharm.2011.08.002","url":null,"abstract":"<div><h3>Background</h3><p><span>Falls are the leading cause of fatal and nonfatal unintentional injury among older adults in the United States. Multifaceted </span>falls prevention programs, which have been reported to reduce the risk for falls among older adults, usually include a medication review and modification component. Based on a literature search, no randomized trials that have examined the effectiveness of this component have been published.</p></div><div><h3>Objective</h3><p>The aim of this article was to report on a retrospective process evaluation of data from a randomized, controlled trial conducted to examine the effectiveness of a medication review intervention, delivered through community pharmacies, on the rate of falls among community-dwelling older adults.</p></div><div><h3>Methods</h3><p>Patients were recruited through 32 pharmacies in North Carolina. Participants were community-dwelling older adults at high risk for falls based on age (≥65 years), number of concurrent medications (≥4), and medication classes (emphasis on CNS-active agents). The process evaluation measured the recruitment of patients into the study, the process through which the intervention was delivered, the extent to which patients implemented the recommendations for intervention, and the acceptance of pharmacists' recommendations by prescribing physicians.</p></div><div><h3>Results</h3><p>Of the 7793 patients contacted for study participation, 981 (12.6%) responded to the initial inquiry. A total of 801 (81.7%) participated in an eligibility interview, of whom 342 (42.7%) were eligible. Baseline data collection was completed in 186 of eligible patients (54.4%), who were randomly assigned to the intervention group (n = 93) or the control group (n = 93). Pharmacists delivered a medication review to 73 of the patients (78.5%) in the intervention group, with 41 recommendations for changes in medication, of which 10 (24.4%) were implemented. Of the 31 prescribing physicians contacted with pharmacists' recommendations, 14 (45.2%) responded, and 10 (32.3%) authorized the changes.</p></div><div><h3>Conclusions</h3><p>Based on the findings from the present study, coordination of care between community pharmacists and prescribers needs to be improved for the realization of potential beneficial effects of medication management on falls prevention.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"9 5","pages":"Pages 310-319.e2"},"PeriodicalIF":0.0,"publicationDate":"2011-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.08.002","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30147557","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-08-01DOI: 10.1016/j.amjopharm.2011.07.003
Jo-Anne Clarke MD , Murray Cutler PhD , Inna Gong BMSc , Ute I. Schwarz MD , David Freeman PhD , Monidipa Dasgupta MD, MSc
Background
The cytochrome P450 (CYP) 2D6 enzyme is involved in the metabolism of many drugs used by the elderly population. Variations in its activity can lead to altered drug response. However, few studies on the activity of this enzyme system have enrolled the elderly population.
Objective
The goal of this pilot study was to assess the feasibility of in vivo phenotyping of CYP2D6 in an elderly population with dementia and to determine if part of the variability in response to treatment with galantamine is attributable to CYP2D6 phenotype.
Methods
Patients with dementia attending geriatric clinics and receiving galantamine treatment for at least 6 months were enrolled in this case-control study. CYP2D6 phenotype was determined by analysis of the urinary concentrations of the probe drug dextromethorphan and its primary metabolite dextrorphan after ingestion of 30 mg of dextromethorphan. Patients were classified as robust responders to galantamine if their cognitive testing, as measured by using scores on the Mini–Mental State Examination or Alzheimer's Disease Assessment Scale–Cognitive subscale, had not changed or had improved after 6 months of treatment.
Results
Forty-three patients (23 men, 20 women; mean age, 78.4 years; 98% white) underwent phenotyping. The mean number of concomitantly prescribed medications was 5.7, and 16 patients (37%) were receiving other CYP2D6 substrate or inhibitor drugs. The distribution of CYP2D6 phenotype was similar to that seen in other white populations. There was no correlation between the phenotypic metabolic ratio and age, the number of routinely taken medications, whether patients were receiving other prescribed substrate or inhibitor drugs of CYP2D6 (P = 0.63), or whether they were a robust responder (P = 0.47).
Conclusions
Urinary assays of CYP2D6 phenotype are technically feasible in older individuals with dementia who are taking multiple medications, and may be a useful clinical tool in this population. However, the study was unable to make inferences about an association between CYP2D6 phenotype and galantamine responsiveness.
{"title":"Cytochrome P450 2D6 Phenotyping in an Elderly Population With Dementia and Response to Galantamine in Dementia: A Pilot Study","authors":"Jo-Anne Clarke MD , Murray Cutler PhD , Inna Gong BMSc , Ute I. Schwarz MD , David Freeman PhD , Monidipa Dasgupta MD, MSc","doi":"10.1016/j.amjopharm.2011.07.003","DOIUrl":"10.1016/j.amjopharm.2011.07.003","url":null,"abstract":"<div><h3>Background</h3><p>The cytochrome P450 (CYP) 2D6 enzyme is involved in the metabolism of many drugs used by the elderly population. Variations in its activity can lead to altered drug response. However, few studies on the activity of this enzyme system have enrolled the elderly population.</p></div><div><h3>Objective</h3><p>The goal of this pilot study was to assess the feasibility of in vivo phenotyping of CYP2D6 in an elderly population with dementia and to determine if part of the variability in response to treatment<span> with galantamine is attributable to CYP2D6 phenotype.</span></p></div><div><h3>Methods</h3><p><span>Patients with dementia attending geriatric<span> clinics and receiving galantamine treatment for at least 6 months were enrolled in this case-control study. CYP2D6 phenotype was determined by analysis of the urinary concentrations of the probe drug </span></span>dextromethorphan<span> and its primary metabolite dextrorphan<span> after ingestion of 30 mg of dextromethorphan. Patients were classified as robust responders to galantamine if their cognitive testing, as measured by using scores on the Mini–Mental State Examination or Alzheimer's Disease Assessment Scale–Cognitive subscale, had not changed or had improved after 6 months of treatment.</span></span></p></div><div><h3>Results</h3><p>Forty-three patients (23 men, 20 women; mean age, 78.4 years; 98% white) underwent phenotyping. The mean number of concomitantly prescribed medications was 5.7, and 16 patients (37%) were receiving other CYP2D6 substrate or inhibitor drugs. The distribution of CYP2D6 phenotype was similar to that seen in other white populations. There was no correlation between the phenotypic metabolic ratio and age, the number of routinely taken medications, whether patients were receiving other prescribed substrate or inhibitor drugs of CYP2D6 (<em>P</em> = 0.63), or whether they were a robust responder (<em>P</em> = 0.47).</p></div><div><h3>Conclusions</h3><p>Urinary assays of CYP2D6 phenotype are technically feasible in older individuals with dementia who are taking multiple medications, and may be a useful clinical tool in this population. However, the study was unable to make inferences about an association between CYP2D6 phenotype and galantamine responsiveness.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"9 4","pages":"Pages 224-233"},"PeriodicalIF":0.0,"publicationDate":"2011-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.07.003","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30044156","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-08-01DOI: 10.1016/j.amjopharm.2011.07.001
Joseph T. Hanlon PharmD, MS (Founding Co-Editor-in-Chief), Kenneth E. Schmader MD (Founding Co-Editor-in-Chief)
{"title":"Dawn of a New Era for the American Journal of Geriatric Pharmacotherapy","authors":"Joseph T. Hanlon PharmD, MS (Founding Co-Editor-in-Chief), Kenneth E. Schmader MD (Founding Co-Editor-in-Chief)","doi":"10.1016/j.amjopharm.2011.07.001","DOIUrl":"10.1016/j.amjopharm.2011.07.001","url":null,"abstract":"","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"9 4","pages":"Page 211"},"PeriodicalIF":0.0,"publicationDate":"2011-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.07.001","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30059633","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-08-01DOI: 10.1016/j.amjopharm.2011.04.009
Leslie Jackson Conwell PhD , Dominick Esposito PhD , Susan Garavaglia PhD , Eric S. Meadows PhD , Margaret Colby MPP , Vivian Herrera MPh , Seth Goldfarb MS , Daniel Ball DrPH , Martin Marciniak PhD
Background
The Medicare Part D coverage gap has been associated with lower adherence and drug utilization and higher discontinuation. Because osteoporosis has a relatively high prevalence among Medicare-eligible postmenopausal women, we examined changes in utilization of osteoporosis medications during this coverage gap.
Objectives
The purpose of this study was to investigate changes in out-of-pocket (OOP) drug costs and utilization associated with the Medicare Part D coverage gap among postmenopausal beneficiaries with osteoporosis.
Methods
This retrospective analysis of 2007 pharmacy claims focuses on postmenopausal female Medicare beneficiaries enrolled in full-, partial-, or no-gap exposure standard or Medicare Advantage prescription drug plans (PDPs), retiree drug subsidy (RDS) plans, or the low-income subsidy program. We compared beneficiaries with osteoporosis who were taking teriparatide (Eli Lilly and Company, Indianapolis, Indiana) (n = 5657) with matched samples of beneficiaries who were taking nonteriparatide osteoporosis medications (NTO; n = 16,971) or who had other chronic conditions (OCC; n = 16,971). We measured average monthly prescription drug fills and OOP costs, medication discontinuation, and skipping.
Results
More than half the sample reached the coverage gap; OOP costs then rose for teriparatide users enrolled in partial- or full-gap exposure plans (increase of 121% and 186%; $300 and $349) but fell for those in no-gap exposure PDPs or RDS plans (decrease of 49% and 30%; $131 and $40). OOP costs for beneficiaries in partial- or full-gap exposure PDPs increased >120% (increase of $144 and $176) in the NTO group and nearly doubled for the OCC group (increase of $124 and $151); these OOP costs were substantially lower than those for teriparatide users. Both teriparatide users and NTO group members discontinued or skipped medications more often than persons in the OCC group, regardless of plan or benefit design.
Conclusion
Medication discontinuation and OOP costs among beneficiaries with osteoporosis were highest for those enrolled in Part D plans with a coverage gap. Providers should be aware of potential cost-related nonadherence among Medicare beneficiaries taking osteoporosis medications.
{"title":"Out-of-Pocket Drug Costs and Drug Utilization Patterns of Postmenopausal Medicare Beneficiaries with Osteoporosis","authors":"Leslie Jackson Conwell PhD , Dominick Esposito PhD , Susan Garavaglia PhD , Eric S. Meadows PhD , Margaret Colby MPP , Vivian Herrera MPh , Seth Goldfarb MS , Daniel Ball DrPH , Martin Marciniak PhD","doi":"10.1016/j.amjopharm.2011.04.009","DOIUrl":"10.1016/j.amjopharm.2011.04.009","url":null,"abstract":"<div><h3>Background</h3><p>The Medicare Part D coverage gap has been associated with lower adherence and drug<span><span> utilization and higher discontinuation. Because osteoporosis has a relatively high prevalence among Medicare-eligible </span>postmenopausal women, we examined changes in utilization of osteoporosis medications during this coverage gap.</span></p></div><div><h3>Objectives</h3><p>The purpose of this study was to investigate changes in out-of-pocket (OOP) drug costs and utilization associated with the Medicare Part D coverage gap among postmenopausal beneficiaries with osteoporosis.</p></div><div><h3>Methods</h3><p>This retrospective analysis of 2007 pharmacy claims focuses on postmenopausal female Medicare beneficiaries enrolled in full-, partial-, or no-gap exposure standard or Medicare Advantage prescription drug plans (PDPs), retiree drug subsidy (RDS) plans, or the low-income subsidy program. We compared beneficiaries with osteoporosis who were taking teriparatide (Eli Lilly and Company, Indianapolis, Indiana) (n = 5657) with matched samples of beneficiaries who were taking nonteriparatide osteoporosis medications (NTO; n = 16,971) or who had other chronic conditions (OCC; n = 16,971). We measured average monthly prescription drug fills and OOP costs, medication discontinuation, and skipping.</p></div><div><h3>Results</h3><p>More than half the sample reached the coverage gap; OOP costs then rose for teriparatide users enrolled in partial- or full-gap exposure plans (increase of 121% and 186%; $300 and $349) but fell for those in no-gap exposure PDPs or RDS plans (decrease of 49% and 30%; $131 and $40). OOP costs for beneficiaries in partial- or full-gap exposure PDPs increased >120% (increase of $144 and $176) in the NTO group and nearly doubled for the OCC group (increase of $124 and $151); these OOP costs were substantially lower than those for teriparatide users. Both teriparatide users and NTO group members discontinued or skipped medications more often than persons in the OCC group, regardless of plan or benefit design.</p></div><div><h3>Conclusion</h3><p>Medication discontinuation and OOP costs among beneficiaries with osteoporosis were highest for those enrolled in Part D plans with a coverage gap. Providers should be aware of potential cost-related nonadherence among Medicare beneficiaries taking osteoporosis medications.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"9 4","pages":"Pages 241-249"},"PeriodicalIF":0.0,"publicationDate":"2011-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.04.009","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30195408","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2011-08-01DOI: 10.1016/j.amjopharm.2011.05.002
Mary T. Roth PharmD, MHS , Denise A. Esserman PhD , Jena L. Ivey PharmD , Morris Weinberger PhD
Background
The quality of medication use in older adults is suboptimal, with a large percentage of individuals not receiving recommended care. Most efforts to evaluate the quality of medication use target high-risk drugs, appropriate treatment of prevalent chronic disease states, or a set of predefined quality indicators of medication use rather than the patient. It is also suggested that racial differences in the quality of medication use may exist in older adults.
Objective
This study was conducted to determine the prevalence, number, and types of medication-related problems in older adults, examining the impact of race on quality medication use.
Methods
This was a prospective cohort study involving in-home interviews and medical record reviews of community-residing older adults, stratified by race, conducted 3 times over 1 year. No intervention to address medication-related problems was performed. The quality of medication use was reported as medication-related problems by clinical pharmacists.
Results
Of the 200 participants (100 blacks, 100 whites), mean age was 78.3 (whites) and 75.5 (blacks), and the majority of patients were female. Although whites used more medications than blacks (mean, 11.6 vs 9.7; P < 0.01), blacks had more medication-related problems per person than whites (mean, 6.3 vs 4.9; P < 0.01). All patients had at least 1 medication-related problem. Common problems at baseline, 6 months, and 12 months for both whites and blacks were undertreatment, suboptimal drug use, suboptimal dosing, nonadherence, and less costly alternative available. Blacks had significantly higher rates of nonadherence than whites (68% vs 42%; P < 0.01). Over the 12-month study, the number of medication-related problems not only persisted but increased (adjusted P = 0.0168).
Conclusions
Medication-related problems were prevalent in both black and white older adults and persisted over 1 year. Blacks had more medication-related problems than whites, including higher rates of nonadherence. These findings require further study to better understand racial disparities in the quality of medication use in older adults and the impact of race on specific medication-related problems.
背景:老年人的药物使用质量是次优的，有很大比例的人没有接受推荐的治疗。大多数评价用药质量的努力都是针对高危药物、对流行慢性病状态的适当治疗或一套预定义的用药质量指标，而不是针对患者。研究还表明，在老年人中，药物使用质量的种族差异可能存在。目的本研究旨在确定老年人药物相关问题的患病率、数量和类型，并研究种族对药物使用质量的影响。方法:这是一项前瞻性队列研究，包括对社区居住老年人的家庭访谈和医疗记录回顾，按种族分层，在1年内进行了3次。未采取干预措施解决药物相关问题。临床药师将用药质量报告为与用药相关的问题。结果200例患者中黑人100例，白人100例，平均年龄78.3岁(白人)，黑人75.5岁(黑人)，以女性为主。尽管白人比黑人使用更多的药物(平均11.6比9.7;P & lt;0.01)，黑人比白人有更多的药物相关问题(平均6.3 vs 4.9;P & lt;0.01)。所有患者至少有1个与药物相关的问题。在基线、6个月和12个月时，白人和黑人的常见问题是治疗不足、次优用药、次优剂量、不依从性和较便宜的替代方案。黑人的不依从率明显高于白人(68% vs 42%;P & lt;0.01)。在12个月的研究中，药物相关问题的数量不仅持续存在，而且有所增加(调整后P = 0.0168)。结论药物相关问题在黑人和白人老年人中普遍存在，且持续1年以上。黑人比白人有更多的药物相关问题，包括更高的不遵医服药率。这些发现需要进一步研究，以更好地了解老年人用药质量的种族差异，以及种族对特定药物相关问题的影响。
{"title":"Racial Disparities in Quality of Medication Use in Older Adults: Findings From a Longitudinal Study","authors":"Mary T. Roth PharmD, MHS , Denise A. Esserman PhD , Jena L. Ivey PharmD , Morris Weinberger PhD","doi":"10.1016/j.amjopharm.2011.05.002","DOIUrl":"10.1016/j.amjopharm.2011.05.002","url":null,"abstract":"<div><h3>Background</h3><p>The quality of medication use in older adults is suboptimal, with a large percentage of individuals not receiving recommended care. Most efforts to evaluate the quality of medication use target high-risk drugs<span>, appropriate treatment of prevalent chronic disease states, or a set of predefined quality indicators of medication use rather than the patient. It is also suggested that racial differences in the quality of medication use may exist in older adults.</span></p></div><div><h3>Objective</h3><p>This study was conducted to determine the prevalence, number, and types of medication-related problems in older adults, examining the impact of race on quality medication use.</p></div><div><h3>Methods</h3><p><span>This was a prospective cohort study involving in-home interviews and </span>medical record reviews of community-residing older adults, stratified by race, conducted 3 times over 1 year. No intervention to address medication-related problems was performed. The quality of medication use was reported as medication-related problems by clinical pharmacists.</p></div><div><h3>Results</h3><p>Of the 200 participants (100 blacks, 100 whites), mean age was 78.3 (whites) and 75.5 (blacks), and the majority of patients were female. Although whites used more medications than blacks (mean, 11.6 vs 9.7; <em>P</em> < 0.01), blacks had more medication-related problems per person than whites (mean, 6.3 vs 4.9; <em>P</em> < 0.01). All patients had at least 1 medication-related problem. Common problems at baseline, 6 months, and 12 months for both whites and blacks were undertreatment, suboptimal drug use, suboptimal dosing, nonadherence, and less costly alternative available. Blacks had significantly higher rates of nonadherence than whites (68% vs 42%; <em>P</em> < 0.01). Over the 12-month study, the number of medication-related problems not only persisted but increased (adjusted <em>P</em> = 0.0168).</p></div><div><h3>Conclusions</h3><p>Medication-related problems were prevalent in both black and white older adults and persisted over 1 year. Blacks had more medication-related problems than whites, including higher rates of nonadherence. These findings require further study to better understand racial disparities in the quality of medication use in older adults and the impact of race on specific medication-related problems.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"9 4","pages":"Pages 250-258"},"PeriodicalIF":0.0,"publicationDate":"2011-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.05.002","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"29928797","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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