American Journal of Geriatric Pharmacotherapy

Goodbyes, Hellos, and Changes

Kenneth E. Schmader, Joseph T. Hanlon — 2012-01-27

The beginning of a new publishing year is an opportune time to reflect on the accomplishments we have enjoyed in 2011 and to look forward to changes in 2012 that will continue to support and ensure the mission of The American Journal of Geriatric Pharmacotherapy (AJGP).

Reconsideration of Key Articles Regarding Medication-Related Problems in Older Adults from 2011

2012-02-01

This year, the oldest baby boomers turned 65 years of age. Baby boomers, which include individuals born between 1946 and 1964, represent 25% of the US population. In addition, given their life experiences, this group of individuals is likely to have higher expectations for the quality of health care services, including medication tolerability. Thus, it is timely to discuss what new knowledge on often preventable medication-related problems (ie, medication errors and medication adverse events) in older adults was published in 2011. Hopefully, by doing so we can begin to develop approaches to reduce medication-related problems and meet this cohort's expectations.

Clostridium Difficile Infection in Older Adults: A Review and Update on Its Management

Vicki R. Kee — 2012-01-20

Abstract: Background: Clostridium difficile is a main cause of health care-associated infections. The incidence and severity have been increasing. Elderly persons are at an increased risk of morbidity and mortality from C. difficile infection (CDI). Relatively few advances have been made in the treatment of CDI since it was first identified as a cause of antibiotic-associated diarrhea more than 30 years ago. Objective: This article reviews CDI and provides an update on its treatment, including recently published clinical practice guidelines and the recently approved drug, fidaxomicin. Methods: English-language literature was identified through a search of PubMed (1966–October 2011), Iowa Drug Information Service (1966–October 2011), and International Pharmaceutical Abstracts (1970–October 2011). Key search terms included Clostridium difficile, Clostridium infections, pseudomembranous colitis, antibiotic-associated diarrhea, Clostridium difficile-associated diarrhea, elderly, geriatric, epidemiology, microbiology, diagnosis, risk factors, treatment, drug therapy, vancomycin, metronidazole, and fidaxomicin. Results: Metronidazole and vancomycin remain the mainstays of CDI treatment. Current guidelines recommend oral metronidazole for initial mild to moderate episodes or first recurrence. Oral vancomycin is recommended for initial severe episodes, or first or second recurrence. Fidaxomicin was approved in 2011 for treatment of CDI, but its place in therapy has yet to be determined. Other antibiotics have been used with variable success. Saccharomyces boulardii is the only probiotic that has shown efficacy in CDI. Fecal transplants have been used successfully in some patients, but randomized studies are needed. Immune therapy with a vaccine and monoclonal antibodies is being studied in clinical trials. Conclusions: Treatment of CDI is challenging due to the limited number of drugs that have proven to be effective, concerns about antibiotic resistance, and recurring disease. The recent approval of fidaxomicin provides a new alternative. Immune therapy will likely play a greater role in the future.

Warfarin Use in Nursing Home Residents: Results from the 2004 National Nursing Home Survey

Parinaz K. Ghaswalla, Spencer E. Harpe, Patricia W. Slattum — 2012-01-09

Abstract: Background: Practice guidelines recommend anticoagulation therapy with warfarin for stroke prevention in patients with atrial fibrillation (AF). Despite this, warfarin is underused in older adults. Objective: The purpose of this study was to determine the prevalence of AF in nursing home (NH) residents and the use of warfarin or other antiplatelet medications in NH residents with AF who have indications for and no contraindications against warfarin use. The secondary objective was to determine the factors associated with warfarin use in NH residents with AF. Methods: Cross-sectional analysis of prescription and resident data files from the 2004 National Nursing Home Survey was performed. Residents with a diagnosis of AF were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, and prescriptions of warfarin and antiplatelet medications were identified using Long-Term Care Drug Database System (LTCDDS) codes. Resident characteristics, stroke risk factors, and potential bleeding risk factors significant at P < 0.10 in χ2 analyses were entered in the final multiple logistic regression model to determine the factors associated with warfarin use. Results: From 13,507 NH residents, 1904 (14%) had a diagnosis of AF and 1767 (13%) had a diagnosis of AF with indications for and no contraindications against warfarin use. Of these 1767 residents, 537 (30%) were prescribed warfarin, and of the remaining 1230 residents who were not prescribed warfarin, 283 (23%) received either aspirin or clopidogrel. Thus, of 1767 residents with AF, with indications for and no contraindications to warfarin use, 947 (54%) residents did not receive any antithrombotic therapy in the form of warfarin, aspirin, clopidogrel, or a combination of these medications. Factors that were significantly associated with increased odds of receiving warfarin were congestive heart failure, previous stroke or transient ischemic attack, deep vein thrombosis or peripheral embolus, valvular heart disease, and total number of medications ≥6. Factors that were significantly associated with reduced odds of receiving warfarin were nonwhite race, history of gastrointestinal bleeding, and use of antiplatelets (ie, clopidogrel). Conclusions: AF is common in NH residents, and more than half of the residents with AF who had indications for and no contraindications against warfarin use were not prescribed either warfarin or antiplatelets, such as aspirin or clopidogrel, suggesting that antithrombotic therapy may be underused in NH residents with AF.

Challenge of Changing Nursing Home Prescribing Culture

Jennifer Tjia, Jerry H. Gurwitz, Becky A. Briesacher — 2012-01-24

Abstract: This article described a framework for improving prescribing in nursing homes (NH) by focusing on the whole facility as a system that has created a “prescribing culture.” We offered this paradigm as an alternative to focused interventions that target prescribers only. We used the example of atypical antipsychotics to illustrate the approach. We also highlighted elements of the NH culture change movement that are germane to medication prescribing, and illustrated which elements of NH culture were shown to be associated with suboptimal quality of care. We concluded by describing current models, including our study funded by the Agency for Healthcare Research and Quality, to identify the best methods of disseminating evidence-based medication use guides in NHs.

Tolerability of Topical Diclofenac Sodium 1% Gel for Osteoarthritis in Seniors and Patients With Comorbidities

Herbert S.B. Baraf, Morris S. Gold, Richard A. Petruschke, Matthew S. Wieman — 2012-01-20

Abstract: Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with a dose-related risk of cardiovascular, renal, and gastrointestinal adverse events (AEs). Topical NSAIDs produce lower systemic NSAID exposure compared with oral NSAIDs, offering potential benefits. Objective: To evaluate the safety of topical diclofenac sodium 1% gel (DSG) for knee and hand osteoarthritis (OA) in older and younger patients and in patients with versus without comorbid hypertension, type 2 diabetes, or cerebrovascular or cardiovascular disease. Methods: Post hoc analysis of pooled data from 5 randomized, double-blind, placebo-controlled trials involving 1426 patients (aged ≥35 years) with mild to moderate OA of the knee and 783 patients (aged ≥40 years) with mild to moderate OA of the hand. Patients applied 4 g of DSG or vehicle to affected knees QID for 12 weeks or 2 g of DSG or vehicle to affected hands QID for 8 weeks. Results: In patients with knee OA, the percentage with ≥1 adverse event was similar in patients aged <65 years (56.6%) versus ≥65 years (55.8%) and was similar in patients with versus without comorbid hypertension (53.4% vs 59.0%, respectively), type 2 diabetes mellitus (50.0% vs 57.2%), or cerebrovascular or cardiovascular disease (53.8% vs 56.5%). In patients with hand OA, the percentage with ≥1 AE was similar in patients aged ≥65 years (42.7%) versus <65 years (39.1%) and was similar in patients with versus without hypertension (39.6% vs 41.7%, respectively), lower in patients with versus without type 2 diabetes mellitus (28.0% vs 41.6%), and higher in patients with versus without cerebrovascular or cardiovascular disease (48.5% vs 39.2%). Gastrointestinal, cardiovascular, and renal AEs were rare and did not differ according to age or comorbidity. Application site reactions were the primary cause for the greater frequency of AEs with DSG versus vehicle. Conclusion: The similar and low rates of AEs in DSG-treated patients aged ≥65 years and <65 years and in those with and without comorbid hypertension, type 2 diabetes, or cerebrovascular or cardiovascular disease suggest that DSG treatment is generally well tolerated.

Medication Adherence Among Geriatric Outpatients Prescribed Multiple Medications

2012-01-24

Abstract: Background: Poor medication adherence (PMA) is associated with higher risks of morbidity, hospitalization, and mortality. Polypharmacy is not only a determinant of PMA but is also associated with many adverse health outcomes. Objective: We aimed to determine the prevalence and correlates of PMA in an older population with polypharmacy. Methods: Baseline data from 193 older adults from the Medication Safety Review Clinic Taiwan Study were analyzed. Patients were either prescribed ≥8 long-term medications or visited ≥3 different physicians between August and October 2007. PMA was defined as taking either <80% or >120% of prescribed amounts of a medication. Patients were classified as no (0%), low level (>0 but <25%), and high level (≥25%) PMA depending on what percentage of entire medication regimen taken reached PMA. Results: Mean (SD) age was 76 (6) years, and mean number of medications was 9 (3), with a mean medication class number of 4 (1). Of the 1713 medications reviewed, 19% had PMA. However, at patient level, 34%, 32%, and 34% of patients were classified as no, low level, and high level PMA, respectively. Correlates varied by levels of PMA. Compared with patients without PMA, higher medication class number and use of alimentary tract, psychotropic, and hematologic agents were associated with both low and high level PMA. History of dizziness was associated with low level PMA, and higher Mini Mental Status Examination score was associated with high level PMA. Conclusions: To enhance medication adherence in older adults prescribed multiple medications, medication class numbers and certain high-risk medication classes should be taken into account. Physicians should also routinely assess systemic (eg, cognition) or drug-specific characteristics (eg, side effects).

The Effect of Dementia on Medication Use and Adherence Among Medicare Beneficiaries With Chronic Heart Failure

2012-01-24

Abstract: Background: Alzheimer's disease and related disorders (ADRD) are prevalent in older adults, increase the costs of chronic heart failure (CHF) management, and may be associated with undertreatment of cardiovascular disease. Objective: The purpose of our study was to determine the relationship between comorbid ADRD and CHF medication use and adherence among Medicare beneficiaries with CHF. Methods: This 2-year (1/1/2006–12/31/2007) cross-sectional study used data from the Chronic Condition Data Warehouse of the Centers for Medicare and Medicaid Services. Medicare beneficiaries with evidence of CHF who had systolic dysfunction and Medicare Parts A, B, and D coverage during the entire study period were included. ADRD was identified based on diagnostic codes using the Chronic Condition Data Warehouse algorithm. CHF evidence-based medications (EBMs) were selected based on published guidelines: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, selected β-blockers, aldosterone antagonists, and selected vasodilators. Measures of EBMs included a binary indicator of EBM use and medication possession ratio among users. Results: Of 9827 beneficiaries with CHF and systolic dysfunction, 24.2% had a diagnosis of ADRD. Beneficiaries with ADRD were older (80.8 vs 73.6 years; P < 0.0001) and more likely to be female (69.3% vs 58.1%; P < 0.0001). Overall EBM use was lower in patients with CHF and ADRD compared with patients with CHF but no ADRD (85.3% vs 91.2%; P < 0.0001). Lower use among those with ADRD was consistent across all EBM classes except vasodilators. Among beneficiaries receiving EBM, those with ADRD had a slightly higher mean medication possession ratio for EBM compared with those without ADRD (0.86 vs 0.84; P = 0.0001). Conclusions: EBM medication adherence was high in this population, regardless of ADRD status. However, patients with ADRD had lower EBM use compared with those without ADRD. Low use of specific EBM medications such as β-blockers was found in both groups. Therefore, interventions targeting increased treatment with specific EBMs for CHF, even among patients with ADRD, may be of benefit and could help reduce CHF-related hospitalizations.

Correction

2012-01-04

In the article by D. Mansour et al, titled “Discontinuation of Acetylcholinesterase Inhibitor Treatment in the Nursing Home,” on page 349 in the October 2011 issue, the Acknowledgments should have read as follows: “Dr. Mansour was responsible for the collection of data.”