American Journal of Geriatric Pharmacotherapy

Risk of Falls and Fractures in Older Adults Using Atypical Antipsychotic Agents: A Propensity Score–Adjusted, Retrospective Cohort Study

Satabdi Chatterjee, Hua Chen, Michael L. Johnson, Rajender R. Aparasu — 2012-02-06

Abstract: Background: Atypical antipsychotic agents are extensively prescribed in the elderly to treat various behavioral and psychiatric disorders. Past literature has documented an increased risk of falls and factures with the use of risperidone and olanzapine compared with nonuse. However, none of the studies assessed the comparative safety profiles of atypical agents with respect to falls and fractures. Objective: The goal of this study was to evaluate the risk of falls and fractures associated with the use of risperidone, olanzapine, and quetiapine in community-dwelling adults aged ≥50 years. Methods: The study involved a propensity score–adjusted approach in new users of risperidone, olanzapine, or quetiapine anytime between July 1, 2000, and June 30, 2008, using data from the IMS LifeLink Health Plan Claims database. Patients were followed up until a hospitalization/emergency department visit for fall/fracture or the end of the study period, whichever occurred earlier. The Cox proportional hazards regression model was used to evaluate the comparative risk of falls/fractures. The covariates in the final model included propensity scores and their interaction terms. Results: There were 12,145 new users of atypical agents in the study population (5083 risperidone, 4377 olanzapine, and 2685 quetiapine). A total of 417 cases of falls/fractures with at least 1 hospitalization/ emergency department visit after the use of the antipsychotic agents were identified. The number of falls for risperidone, olanzapine, and quetiapine were 179 (3.56%), 123 (2.84%), and 115 (4.34%), respectively. After adjusting for propensity scores, the Cox proportional hazards model showed that there was no statistically significant difference with use of risperidone (hazard ratio = 1.10 [95% CI, 0.86–1.39]) or quetiapine (hazard ratio = 1.12 [95% CI, 0.86–1.46]) compared with olanzapine (reference group) in the risk of falls or fractures. Conclusions: The study found no significant difference across the individual atypical agents in the risk of falls/fractures in community-dwelling older adults. Future studies are required to evaluate the overall safety profiles of the antipsychotic agents in this population.

Role of the Pharmacist on a General Medicine Acute Care for the Elderly Unit

Timothy Reilly, David Barile, Stanley Reuben — 2012-03-05

Abstract: Background: The prevalence of prescription medication use increases with age, and older adults are at increased risk of harm from medication use. Objective: To describe the role of a pharmacist on a General Medicine Acute Care of the Elderly (GM-ACE) Unit. Methods: A job description was prepared, and a clinical pharmacist specializing in internal medicine was re-assigned to participate in multidisciplinary rounds on the ACE unit twice weekly and to work with a unit-based pharmacist assigned to multiple units. The clinical pharmacist also provided formal education on geriatric pharmacotherapy for other health care providers. Interventions were defined as changes in the medical record and provision of drug information. Interventions were tracked with an existing form and sorted by category. Data on interventions were presented to the pharmacy and therapeutics committee routinely. Results: After 3 months, the clinical pharmacist accomplished 76 interventions in the areas of agent selection, dose optimization, addition of therapy, deletion of therapy, medication reconciliation, intravenous to oral conversion, technology improvements, and drug information/patient education. Conclusion: Expanding the role of the pharmacist in a GM-ACE unit has improved the medication use process in a high-risk population through improvements in medication overuse, medication underuse, dosing, medication reconciliation, patient education, and health care provider education.

Applicability of an Adapted Medication Appropriateness Index for Detection of Drug-Related Problems in Geriatric Inpatients

2012-02-03

Abstract: Background: High drug consumption by older patients and the presence of many drug-related problems require careful assessment of drug therapy, for which a structured approach is recommended. Objective: The purpose of our study was to evaluate the applicability of an adapted version of the Medication Appropriateness Index (MAI) in 50 geriatric inpatients at the time of admission. Methods: We reviewed, for 432 prescribed drugs, indication, right choice, dosage, directions, drug–disease interactions, drug–drug interactions, and duration of therapy. In addition, adverse drug reactions were evaluated, resulting in 8 questions per drug. MAI scores were attributed independently by a geriatrician and by a clinical pharmacist, and differences between them were assessed. Furthermore, the relationship between MAI score and drug-related hospital admission was explored. Results: Mean summed MAI scores of 13.7 according to the geriatrician and 13.6 according to the pharmacist were obtained. The highest scores were found for drugs for the central nervous and the urinary tract system; the highest scores per question were detected for right choice, adverse drug reactions, and drug–drug interactions. A good agreement between the scores of the geriatrician and the pharmacist was found: intraclass correlation coefficient was 0.91 and overall κ value was 0.71. A significantly higher MAI score was found for drug-related hospital admissions (P = 0.04 for the geriatrician and P = 0.03 for the pharmacist). Conclusions: This adapted MAI score seems useful for detection of drug-related problems in geriatric inpatients and reliable with a low inter-rater variability and positive correlation between high score and drug-related hospital admission. We consider further application of the adapted MAI for teaching and training of clinical pharmacists, and as a systematic approach for detection of drug-related problems by the clinical pharmacists in our hospital.

Complexity of Medication Use in Newly Diagnosed Chronic Obstructive Pulmonary Disease Patients

2012-01-27

Abstract: Background: To better understand how medications have been used and the complexity of regimens used to treat patients, we characterized patterns of medication use and the degree to which patients used different classes of medications in combination and over time in a cohort of newly diagnosed chronic obstructive pulmonary disease (COPD) patients. Objective: The objectives of this study were to characterize patterns of medication use, including the degree to which patients used different classes of medications in combination and over time within a cohort of newly diagnosed COPD patients and to identify the proportion of patients who had gaps in filling their prescriptions. Methods: We identified a cohort of patients from the Veterans Affairs health care system with newly diagnosed COPD between 1999 and 2003. Using prescription fill information, we quantified the prevalence and incidence of exposure to short-acting β-agonists (SABAs), long-acting β-agonists (LABAs), short-acting anticholinergics (eg, ipratropium [IPRA]), and inhaled corticosteroids (ICSs) over 1 year. We additionally characterized the sequencing of medication addition and discontinuation and gaps between prescription fills. The prevalence of multiple respiratory medication use was summarized at 90, 180, and 365 days of follow-up. Results: Of 133,737 patients with newly diagnosed COPD, the majority (80.0%) used a SABA, followed by 40.0% using IPRA, 33.2% using an ICS and 16.0% using a LABA during the 1-year follow-up. Medication changes were frequent, with 57.7% of patients having a medication addition and 48.6% discontinuing medication. The sequence of medication changes varied greatly across patients. Multiple respiratory medication use was common, with 29% of patients dispensed 3 to 4 medication classes in 1 year. Conclusions: Many COPD patients who are started on medication management undergo changes in prescribed pharmacotherapy and are taking multiple medications. Despite clinical practice guidelines, there is an ad hoc nature of COPD medication management, and such heterogeneity challenges the ability to estimate relationships between drug exposure and outcomes using real-world data.

Polypharmacy With Common Diseases in Hospitalized Elderly Patients

Fumihiro Mizokami, Yumiko Koide, Takeshi Noro, Katsunori Furuta — 2012-03-05

Abstract: Background: Elderly persons are exposed to polypharmacy because of multiple chronic conditions. Many risk factors for polypharmacy have been identified including age, race/ethnicity, sex, educational achievement level, health status, and number of chronic diseases. However, drugs prescribed for individual diseases have not been analyzed. Objective: The objective of this study was to analyze each common disease in the elderly with respect to prescribed drugs and polypharmacy. Methods: A 1-year (January through December 2009) cross-sectional study was performed in which all drugs given to hospitalized elderly patients (age, >65 years) were investigated. Common diseases of the elderly were separated into disease groups including hypertension, hyperlipidemia, gastric ulcer, previous stroke, reflux esophagitis, diabetes mellitus, malignancy, osteoporosis, angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, dementia, and depression. Results: Among 1768 elderly patients, the mean (range) age of study patients was 78 (65 to 100) years. The mean (SD) number of diseases was 7.7 (3.4), and the number of drugs overall was 4.9 (3.6). The number of drugs and prevalence of polypharmacy were hypertension, 5.2 (3.9 [51%]); hyperlipidemia, 5.6 (3.8 [58%]); gastric ulcer, 5.4 (3.8 [53%]); previous stroke, 5.8 (3.2 [61%]); reflux esophagitis, 5.6 (3.8 [40%]), diabetes mellitus, 5.6 (3.1 [54%]); malignancy, 4.1 (3.1 [37%]); osteoporosis, 5.4 (3.4 [45%]); angina pectoris, 5.7 (3.6 [42%]); congestive heart failure, 6.1 (4.0 [60%]); chronic obstructive pulmonary disease, 5.0 (3.5 [53%]); dementia, 5.1 (3.2 [52%]); and depression, 7.0 (4.2 [73%]). Conclusions: When assessing the risk of polypharmacy, physicians should carefully consider the type of any chronic disease. Elderly patients with multiple diseases may be subjected to further polypharmacy.

Design of a Medication Therapy Management Program for Medicare Beneficiaries: Qualitative Findings From Patients and Physicians

2012-01-27

Abstract: Background: The quality of pharmacologic care provided to older adults is less than optimal. Medication therapy management (MTM) programs delivered to older adults in the ambulatory care setting may improve the quality of medication use for these individuals. Objectives: We conducted focus groups with older adults and primary care physicians to explore (1) older adults' experiences working with a clinical pharmacist in managing medications, (2) physician perspectives on the role of clinical pharmacists in facilitating medication management, and (3) key attributes of an effective MTM program and potential barriers from patient and provider perspectives. Methods: Five focus groups (4 with older adults, 1 with physicians) were conducted by a trained moderator using a semistructured interview guide. Each participant completed a demographic questionnaire. Sessions were recorded, transcribed verbatim, and analyzed using qualitative analysis software for theme identification. Results: Twenty-eight older adults and 8 physicians participated. Older adults valued the professional, trusting nature of their interactions with the pharmacist. They found the clinical pharmacist to be a useful resource, thorough, personable, and a valuable team member. Physicians believe that the clinical pharmacist fills a unique role as a specialized practitioner, contributing meaningfully to patient care. Physicians emphasized the importance of effective communication, pharmacist access to the medical record, and a mutually trusting relationship as key attributes of a program. Potential barriers to an effective program include poor communication and lack of familiarity with the patient's history. The lack of a sustainable reimbursement model was cited as a barrier to widespread implementation of MTM. Conclusions: This study provides information to assist pharmacists in designing MTM programs in the ambulatory setting. Key attributes of an effective program include being comprehensive and addressing all medication-related needs over time. The clinical pharmacist's ability to build trusting relationships with patients and providers is essential.

Age-Related Changes in Antidepressant Pharmacokinetics and Potential Drug-Drug Interactions: A Comparison of Evidence-Based Literature and Package Insert Information

Richard D. Boyce, Steven M. Handler, Jordan F. Karp, Joseph T. Hanlon — 2012-01-30

Abstract: Background: Antidepressants are among the most commonly prescribed psychotropic agents for older patients. Little is known about the best source of pharmacotherapy information to consult about key factors necessary to safely prescribe these medications to older patients. Objective: The objective of this study was to synthesize and contrast information in the package insert (PI) with information found in the scientific literature about age-related changes of antidepressants in systemic clearance and potential pharmacokinetic drug–drug interactions (DDIs). Methods: A comprehensive search of two databases (MEDLINE and EMBASE from January 1, 1975 to September 30, 2011) with the use of a combination of search terms (antidepressants, pharmacokinetics, and drug interactions) was conducted to identify relevant English language articles. This information was independently reviewed by two researchers and synthesized into tables. These same two researchers examined the most up-to-date PIs for the 26 agents available at the time of the study to abstract quantitative information about age-related decline in systemic clearance and potential DDIs. The agreement between the two information sources was tested with κ statistics. Results: The literature reported age-related clearance changes for 13 antidepressants, whereas the PIs only had evidence about 4 antidepressants (κ < 0.4). Similarly, the literature identified 45 medications that could potentially interact with a specific antidepressant, whereas the PIs only provided evidence about 12 potential medication–antidepressant DDIs (κ < 0.4). Conclusion: The evidence-based literature compared with PIs is the most complete pharmacotherapy information source about both age-related clearance changes and pharmacokinetic DDIs with antidepressants. Future rigorously designed observational studies are needed to examine the combined risk of antidepressants with age-related decline in clearance and potential DDIs on important health outcomes such as falls and fractures in older patients.

Commentary on the New American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Zachary A. Marcum, Joseph T. Hanlon — 2012-04-01

Recently, the American Geriatrics Society (AGS) Beers criteria were unveiled as a measure of potentially inappropriate medication use in older adults. We thought that it would be timely and relevant to comment on this updated quality measure for medication use. Of note, a recent systematic review summarized the current literature on the more than a dozen measures of potentially inappropriate prescribing in older adults and reported that the Beers criteria and the Screening Tool of Older Persons' Prescriptions (STOPP) criteria were some of the most commonly used measures. With that in mind, in this commentary, we discuss some of the history of the Beers criteria as well as briefly describe the process of updating the criteria, highlighting some of the key changes made. Then, we compare and contrast the new criteria with the STOPP criteria from Europe. Finally, we briefly comment on some future directions for the Beers criteria as an explicit measure of potentially inappropriate medication use in older adults.

Clinical Challenges in a Patient With Dabigatran-Induced Fatal Hemorrhage

Ennie L. Cano, Marta A. Miyares — 2012-03-05

Abstract: Objective: To report clinical challenges in managing dabigatran-induced bleeding. Methods: A 78-year-old woman came to the hospital with severe coagulopathy, respiratory failure, hypotension, and bleeding secondary to dabigatran therapy. At admission, creatinine clearance was 15 mL/min; prothrombin time, 147.5 seconds; activated partial thromboplastin time, >200 seconds; and international normalized ratio, 12.42. Medications taken at home included dabigatran, 150 mg BID. During the hospitalization, multiple blood product transfusions were given, vitamin K and prothrombin complex concentrate were administered, and dialysis was initiated in an attempt to achieve hemostasis. Despite multiple interventions, coagulopathy persisted (prothrombin time, 70.8 seconds; activated partial thromboplastin time, >200 seconds; and international normalized ratio, 6.05), with continued bleeding. On hospital day 5, the patient died. Conclusions: According to the Naranjo probability scale, bleeding associated with dabigatran revealed a probable relationship. This fatal case illustrates our concern about the usefulness of currently recommended anticoagulation laboratory tests and of the efficacy of blood transfusion, dialysis, and prothrombin complex concentrate in managing life-threatening bleeding secondary to dabigatran. In addition, clinicians should be cognizant of the renal recommendations for the newer oral anticoagulant agents to prevent potentially catastrophic results.

Editorial Board

2012-04-01