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PubMed2006

Improper intake of medication by elders--insights on contributing factors: a review of the literature.

Elders represent 6.4% of the world's populations, and 60% of them take medication. In one of six hospital admissions of elders, failures in medication intake are involved. Most of these admissions (88%) could be prevented if elders at risk can be identified (Beijer & Blaey, 2002). This review was conducted to identify and gain insight into which factors influence medication intake in elders. The factors are grouped into six categories: physiological factors, cognitive factors, polypharmacy and medication frequency, patient consent to the treatment and motivation for taking the medication, demographic variables, and family caregivers and social support. In order to identify elders at risk in an early stage, it is recommended that a risk-assessment instrument be developed.

Aged↗

PubMed2005

Risk of adverse drug events by patient destination after hospital discharge.

PURPOSE: The prevalence of risk factors for adverse drug events (ADEs) in patients discharged from the hospital to various care settings was studied. METHODS: Data on patient risk characteristics for ADEs were collected for hospital discharges for 2000. Differences in the prevalence of 10 risk characteristics among home health care (HHC), self-care (SC), and long-term-care (LTC) patients at the point of discharge were determined. RESULTS: Data for 4250 discharges were analyzed. The three groups differed significantly in the distribution of risk characteristics. HHC patients had the highest prevalence of heart failure, cardiovascular medication use, and polypharmacy, and LTC patients had the highest prevalence of hypoalbuminemia, cognitive impairment, and psychiatric drug use. CONCLUSION: The risk of ADEs in patients discharged to HHC appeared to be comparable to or higher than that in patients discharged to LTC.

Adverse Drug Reaction Reporting Systems↗

PubMed2000

Patient-oriented strategies for the prevention of drug interactions.

Drug interactions are a common and serious problem arising from polypharmacy. Strategies to reduce the likelihood of the co-prescription of hazardous drug combinations are likely to enhance the quality of care provided for patients requiring polypharmacotherapy. Drugs for which patient-oriented information strategies may decrease the likelihood of drug interactions tend to be those of low therapeutic index. and have interaction potential with other drugs commonly prescribed or available without prescription.

Drug Interactions↗

PubMed2004

Prescription of hazardous drugs during pregnancy.

BACKGROUND: Prescribing drugs to pregnant women requires the balancing of benefits and risks. Only a small proportion of drugs are known to be harmful to the fetus, but for the vast majority of drugs little evidence of fetal safety exists. AIM: To determine the prescription pattern of potentially and clearly harmful prescription drugs during pregnancy with reference to drug safety categorisation, and to define the drug groups primarily responsible for multiple drug use during pregnancy. STUDY DESIGN: A retrospective, register-based cohort study. METHODS: Linkage of three nationwide registers in Finland. Data collection included prescription drugs purchased during the preconception period and each trimester in the pregnant cohort, and the corresponding time periods in the non-pregnant controls. The pregnancy safety categorisation was determined for each drug (Anatomic Therapeutic Chemical [ATC] code) by using the Swedish classification of approved medicinal products (Farmaceutiska Specialiteter i Sverige [FASS]) and if not available, the corresponding Australian (Australian Drug Evaluation Committee [ADEC]) or US categorisation (FDA). GROUPS STUDIED: Women applying for maternity support (maternal grants) during the year 1999 (n = 43 470) plus non-pregnant control women matched by age and hospital district (n = 43 470). RESULTS: In the pregnant cohort, 20.4% of women purchased at least one drug classified as potentially harmful during pregnancy, and 3.4% purchased at least one drug classified as clearly harmful. A significant decline occurred in the number of pregnant women purchasing potentially and clearly harmful drugs during the first trimester when compared with the preconception period, and the decline continued from the first to the second trimester. In the pregnant cohort, 107 (0.2%) women purchased at least ten different drugs during pregnancy. The drugs most commonly purchased in this group were topical corticosteroids and nasal preparations. CONCLUSION: The use of hazardous prescription drugs declines during pregnancy but prescriptions of known teratogens and the relatively frequent practice of polypharmacy in epilepsy place emphasis on the need for careful pre-pregnancy counselling. However, drug safety classifications give a very crude estimation of risk and should only be used as general guidelines when planning treatment. Risk assessment must always be made on an individual basis, and pregnant women with illnesses requiring treatment must be treated adequately.

Administration, Intranasal↗

PubMed2006

The prevalence of potential drug-drug interactions in patients with heart failure at hospital discharge.

BACKGROUND/OBJECTIVE: Pharmacotherapy for heart failure is complex and, due to polypharmacy, is associated with a large risk of potential drug-drug interactions (DDIs). The objective of the present study was to assess the prevalence of potential DDIs in the medication of hospitalised heart failure patients and to evaluate their clinical relevance. STUDY DESIGN/METHODS: The medication of 400 patients was retrospectively analysed for potential DDIs at hospital admission and discharge using a computerised drug interaction program. Main inclusion criteria were the diagnosis of heart failure and a minimum of two drug prescriptions at discharge. RESULTS: In the study population of 400 heart failure patients (median age 79 years, 55.5% men), the median number of drugs per patient was lower at admission than at discharge (6 [interquartile range {IQR} 4-9] vs 8 [IQR 6-10]; p < 0.001). At hospital admission, a total of 863 potential DDIs were detected in 272 patients (68.0%; 95% CI 63.4, 72.6). At discharge, 1171 potential DDIs were detected in 355 patients (88.8%; 95% CI 85.7, 91.8). This corresponds with a significant increase in the median number of potential DDIs per patient from admission to discharge (1.5 [IQR 0-3] vs 3 [IQR 1-4]; p < 0.001). Of the 1171 potential DDIs at discharge, 432 (36.9%) were prevalent at admission and 739 (63.1%) resulted from a medication change during the hospital stay. Of these 739 new potential DDIs, the severity of the potential adverse effect was rated as 'major' in 190 (25.7%) patients, 'moderate' in 482 (65.2%) and 'minor' in 67 (9.1%). The 190 potential DDIs with major severity were recorded in a total of 145 patients (36.3%; 95% CI 31.5, 41.0%). Hyperkalaemia was the most prevalent potential adverse effect of major severity (n = 93) and the combination of an ACE inhibitor with a potassium-sparing diuretic was recorded in 64 (16.0%) patients. CONCLUSIONS: The study shows that hospitalisation of patients with heart failure results in an increase in the number of drugs prescribed per patient and, thereby, also in the number of potentially interacting drug combinations per patient. Although electronic drug interaction programs are a valuable tool to check for potential DDIs, the clinical relevance of most potential DDIs can only be judged by assessment of the individual patient.

Aged↗

PubMed1997

Prescribing patterns for nursing home residents in the US. The reality and the vision.

The study of prescribing for the elderly in the US is in its infancy. Nursing home studies provide some of the most reliable data. In US nursing homes, each resident is prescribed an average of between 7.2 and 8.1 medications, with gastrointestinal agents being the most frequent. The vision for prescribing in the US involves avoidance of polypharmacy and specific groups of medications. Approaches to treatment in the US for certain conditions that can be prevented are addressed, specifically pain control, osteoporosis, stroke, cardiovascular disease, cognitive impairment and infection.

Aged↗

PubMed2004

Anaesthesia in elderly patients with neurodegenerative disorders: special considerations.

Neurodegenerative diseases are increasingly common in elderly patients, who present a particular anaesthetic challenge. The majority of people over the age of 70 years have some degree of cerebral atrophy. The pathogenesis of neurodegenerative diseases is due to alterations in the transport, degradation and aggregation of proteins. Alterations in physiology that occur with advancing age affect both the pharmacokinetics and pharmacodynamics of drugs used in the elderly. Changes in pharmacokinetics result in either increased or reduced drug concentrations depending on the variable contributions of absorption, metabolism and elimination. The distribution of a drug depends on its protein binding, cardiac output and blood volume, which are all altered in the elderly. Metabolism and excretion of drugs are also affected due to changes in hepatic and renal mass and blood flow in the elderly. A number of drugs are used in neurodegenerative disorders including antidepressants, benzodiazepines, antipsychotics, acetylcholinesterase inhibitors and levodopa. Polypharmacy is a common problem, which can lead to adverse drug interactions and an exacerbation of dementia. Levodopa, bromocriptine and tricyclic antidepressants are known to cause orthostatic hypotension in patients with neurodegenerative disease. Elderly patients are liable to excessive sedation from benzodiazepines in both the pre- and postoperative period; therefore these drugs should be prescribed in low doses. For induction of general anaesthesia propofol is a suitable agent in patients with neurodegenerative disease due to its rapid metabolism, but may not be suitable in patients with Parkinson's disease as it can induce spontaneous involuntary movements. Volatile inhalational agents should be administered carefully in the elderly, as they are more sensitive to the depressant cerebral and cardiovascular effects. Levodopa should be avoided in conjunction with halothane, which sensitises the heart to catecholamines. Co-administration of monoamine oxidase inhibitors and opioids should be avoided as it can cause agitation, muscular rigidity, sweating and hyperpyrexia. If an anticholinergic agent is required, then glycopyrronium bromide is the drug of choice in this group of patients, as it does not cross the blood brain barrier. Patients should continue to take their usual medications in hospital and do not let the change in routine alter the times at which treatments are administered. This is particularly relevant to the timing of levodopa in Parkinson's disease, as missed treatment can be detrimental. Regional anaesthesia may, however, have significant advantages in patients with Parkinson's disease, who can continue to take oral levodopa preoperatively, during surgery, if required, and early in the postoperative period. Anti-emetic drugs such as phenothiazines, butyrophenones and metoclopramide should be used carefully in the postoperative period in these patients as their antidopaminergic effects may induce or exacerbate parkinsonian effects.

Aged↗

PubMed2004

Drug therapy in transplant recipients: special considerations in the elderly with comorbid conditions.

Elderly patients with end-stage organ failure are now more frequently undergoing transplantation. Medication management in this population is challenging because of the combination of multiple comorbidities, polypharmacy, and immunological, pharmacokinetic and pharmacodynamic changes attributable to the aging process. Immunosuppressive medications can exacerbate pre-existing medical conditions and promote the development of disease processes. Cardiovascular disorders, such as hypertension, coronary artery disease, congestive heart failure and arrhythmias are common in elderly transplant recipients, and account for most of the deaths in this population. Blood pressure, blood glucose and cholesterol control is of particular concern because elderly transplant recipients frequently have or develop these complications. Elderly transplant recipients are commonly receiving anticoagulation therapy with warfarin and are at a higher risk of bleeding, especially if they have renal dysfunction. Infectious complications occur frequently in the transplanted population, with pneumonia being the most common infection seen in hospitalised patients. Attention to vaccination for the prevention of influenza and pneumococcal infections is important because of the increased risk of these diseases in this population. Depression itself has been associated with decreased survival in older individuals, and depression in elderly transplant recipients may be reversible with the administration of pharmacological agents. Effective long-term care of transplant recipients demands an understanding of how particular medications affect clinical evaluation and treatment. This article addresses some of the practical issues surrounding medication management and prevention of these particular problems in elderly transplant recipients.

Aged↗

PubMed2004

Hypoglycaemia in elderly patients with diabetes mellitus: causes and strategies for prevention.

Achieving target glycaemic goals while avoiding hypoglycaemia is a major challenge in the management of elderly patients with diabetes mellitus. Repeated episodes of hypoglycaemia may cause extreme emotional distress in such patients, even when the episodes are relatively mild. Moreover, evidence is mounting that hypoglycaemia among elderly patients is a very real and costly health concern. The strongest predictors of severe hypoglycaemia in the elderly are advanced age, recent hospitalisation and polypharmacy. Education is the key to preventing recurrent or severe hypoglycaemia. As such, there should be close coordination of care between the patient, physician and all other healthcare providers in identifying the cause of hypoglycaemia in elderly patients, and appropriate steps should be taken to prevent further episodes. Prevention of hypoglycaemia has the potential to improve psychosocial aspects of elderly health, including enhanced quality of life, boosted confidence, improved compliance with antidiabetic regimens and avoidance of long-term complications. Since the elderly population represents a unique group, it is imperative to focus on the aetiologies that are exclusive to this group. Advanced age itself is a risk factor for hypoglycaemia, and elderly patients with comorbidities are at increased risk when they are hospitalised. Elderly patients with diabetes often have compromised renal function, which intereferes with drug elimination and thus predisposes them to prolonged life-threatening hypoglycaemia. In addition, patients on five or more prescription medications are prone to drug-associated hypoglycaemia. Although sulfonylurea-associated hypoglycaemia is common, drugs such as ACE inhibitors and nonselective beta-adrenoceptor antagonists can also predispose patients to hypoglycaemia. Greater attention should be paid to the avoidance of hypgolycaemia in nursing home residents. Recurrent hypoglycaemia in elderly patients is not only detrimental to achieving good glycaemic control, it is also a substantial economic burden. Once the causes of hypoglycaemia have been identified, it is crucial to formulate and institute a prevention plan. Firstly, global evaluation of the patient should be carried out to identify possible predisposing risk factors. Secondly, target glycaemic goals should be tailored to each patient. Thirdly, selection of antidiabetic agents should be judicious, then patients and family should be educated to recognise and treat hypoglycaemia. Finally, coordinated care should be provided to identify, treat and prevent hypoglycaemia.

Adrenergic beta-Antagonists↗

PubMed2005

Improving elder care by integrating geriatric expertise into medicare: a proposal.

The Medicare programme already funds a large proportion of the medical care for older Americans. However, geriatricians are an underutilized resource for improving the quality of care delivered with Medicare funding, particularly to the most complex patients. Recent legislative changes will increase the involvement of the Medicare programme in the area of outpatient medications. This offers an important opportunity to bring geriatric consultation to bear on a broad range of geriatric prescribing issues, including polypharmacy, pharmacological undertreatment and inappropriate prescription choice.

Aged↗

PubMed2006

Evaluation of pharmacotherapy in geriatric patients after performing complete geriatric assessment at a diagnostic day clinic.

BACKGROUND: Elderly patients often take multiple drugs. It is known that polypharmacy, i.e. use of five or more drugs, may lead to drug interactions and adverse events. However, undertreatment of conditions or illnesses is also a concern in geriatric patients. A centralised review of both diagnoses and medication may play a key role in optimising pharmacotherapy in geriatric patients. The aims of this study were to evaluate the quality and appropriateness of medication after performing a complete geriatric assessment (CGA) and medication review at a diagnostic geriatric day clinic, to investigate reasons for drug changes, and to determine whether medication review leads to a reduction in the number of drugs used. METHODS: A chart review was performed in 702 patients (mean age 82.0 years, range 57.1-104.1 years) who underwent a CGA at a diagnostic geriatric day clinic. Medication at admission, changes in medication and reasons for changes were noted. RESULTS: Vitamins, for example folic acid and vitamin B(12) (cyanocobalamin), and trimethoprim for urinary tract infections were the most frequently started medications after CGA and medication review. The number of drugs used was reduced in only a minority of patients (11.7%); reasons for discontinuation were a diagnosis that was no longer relevant (38.8%), adverse events (33.2%) and identification of better pharmacotherapeutic options (22.0%). In 69.2% of the cases a new diagnosis was the reason for starting a new medication, followed by osteoporosis prophylaxis (15.0%) and improvement in pharmacotherapy (10.6%). At admission, patients were taking a mean number of 4.6 drugs (range 0-17). A mean of 0.8 drugs (range from reduction of 5 to addition of 7) had been added per patient, resulting in a mean number of 5.4 (range 0-18) prescribed drugs at discharge. CONCLUSION: Evaluation of medication in patients after performing CGA at the geriatric day clinic investigated resulted in relevant medication changes. The main reason for prescribing new drugs was a new diagnosis. Absence of a relevant medical indication was the main reason for stopping drugs. CGA and medication review resulted in a mean net addition of 0.8 drugs per patient.

Aged↗

PubMed1998

Use of amphetamine-like appetite suppressants: a cross-sectional survey in Southern Brazil.

In 1994 a cross-sectional survey was undertaken in Pelotas, Southern Brazil, to assess the prevalence of amphetamine-like appetite suppressant use. 1,277 adults were interviewed, and the prevalence of anorectic drug use was 1.3% (95% CI = 0.7-1.9): 15 women and one man, mainly from higher socioeconomic groups. Most of the users (81%) had a medical prescription. Forty-one different drugs had been prescribed. Mean length of use was 8.7 months. These findings are discussed in terms of the overreliance on anorectics as aids to dieting, the dangers of polypharmacy, and the risks of long-term use.

Adolescent↗

PubMed1999

Antidepressant drug interactions in the elderly. Understanding the P-450 system is half the battle in reducing risks.

Antidepressant treatment in patients 65 years of age or older carries increased risks of adverse drug events because of age-related physiologic changes, polypharmacy, and individual variability in drug metabolism (due to genetic factors, concurrent disease, diet, and consumption habits). Reduction of total drug burden, adjustment of dose levels, and careful selection of an appropriate agent are important steps toward avoiding adverse drug interactions, In addition, the documented and potential drug interactions of the various classes of antidepressants, and specific agents within each class, should be considered. Each elderly patient should be treated individually and monitored carefully during the initiation and maintenance of antidepressant therapy.

Adrenergic Uptake Inhibitors↗

PubMed2005

Teaching older adults to self-manage medications: preventing adverse drug reactions.

Older adults use more prescription and OTC medications than any other age group. Because their medication regimens often are complicated by many medications and different doses, times, and administration methods, older adults are at high risk for medication mismanagement. The most common errors associated with medication mismanagement include mixing OTC and prescription medications, discontinuing prescriptions, taking wrong dosages, using incorrect techniques, and consuming inappropriate foods with specific medications. Both human and environmental factors contribute to medication mismanagement among older adults. Human factors include faulty communication between the health care provider and the patient; the patient's lack of knowledge; ADRs; alcohol-drug interactions; use of OTC medications and herbal products; cognitive, sensory, and motor impairments; and polypharmacy. Environmental factors include high cost of prescribed medications, improper medication storage, and absence of clearly marked expiration dates. Nurses need to take advantage of both formal and informal teaching opportunities in all settings to prepare a patient for medication self-management. Teaching should be individualized and based on a thorough assessment of the patient's abilities to administer medication safely and the specific medication regimen. By involving older adults as active partners in their health care, many errors and medication-related health problems can be prevented. New technologies and devices have the potential for improving the patient's self-management of medications. The role of nurses in educating older adults and their families about proper medication management is vital.

Aged↗

PubMed2006

Evidence-based guideline. Improving medication management for older adult clients.

All providers and professionals who care for older adults have an important role to play in the process of managing medications. The evidence-based guideline "Improving Medication Management for Older Adult Clients" (Bergman-Evans, 2004) provides assessments and interventions that are useful across settings. By focusing on reducing inappropriate prescribing, decreasing polypharmacy, avoiding adverse events, and maintaining function, professionals and providers have the opportunity to improve outcomes for this important population.

Aged↗

PubMed2003

Conventional antipsychotic prescription in unipolar depression, I: an audit and recommendations for practice.

BACKGROUND: Despite narrow indications for conventional antipsychotics in depression, recent reports confirm a suspicion that they are widely prescribed in nonpsychotic depressive conditions. METHOD: Data from the case notes of over 510 patients with unipolar depression (unvalidated clinical diagnoses) were collected between June 1997 and January 1998 from community and acute units in 1 National Health Service (NHS) Trust. The aim of this audit was to assess the extent and pattern of antipsychotic prescription in this sample. RESULTS: More than a quarter (N = 138) of the sample (N = 494) were currently prescribed an antipsychotic; 40% of these received an antipsychotic without any recognized indication. The mean time on antipsychotic therapy was 3 years. Patients on antipsychotic therapy were, on average, taking twice as many total medications as those not on antipsychotic therapy. Patients with psychotic depression were taking an average of nearly twice the antipsychotic dose of nonpsychotic patients. CONCLUSION: Current clinical guidelines commend careful antidepressant choice in preference to polypharmacy. A number of drug choices for specific depressive presentations are summarized from recent sources.

Adolescent↗

PubMed2003

Conventional, atypical, and combination antipsychotic prescriptions: a 2-year comparison.

BACKGROUND: The purpose of this study was to determine if there is a relationship between the type of antipsychotic prescribed (conventional, atypical, or a combination) and patients' use of psychiatric services and prescription of adjuvant medications. METHOD: A chart review of 83 outpatients with long-term psychiatric disorders recorded the type and dosage of psychiatric medications prescribed in 1997-1998 (T1) and 2 years later, in 1999-2000 (T2). Psychiatric service use was also noted during the 2-year follow-up. RESULTS: Atypical prescriptions increased from 27% (N = 22) to 45% (N = 37) 2 years later. At T2, 35% of patients (N = 29) were prescribed conventionals, and 19% (N = 16) were prescribed a combination of conventionals and atypicals. The mean antipsychotic dosage in chlorpromazine equivalents (546.5 mg/day) increased significantly (p <.05). There was no difference between the 3 groups in their use of psychiatric services or the prescription of adjuvant medications, with the exception of less common prescription of anticholinergics. There was also no difference in psychiatric service use between patients who remained on treatment with combined antipsychotics at T1 and T2 (11%; N = 9) and the rest of the sample. Patients who were switched from one type of antipsychotic to another made more use of psychiatric services, however. CONCLUSION: Contrary to our expectations, patients prescribed combined antipsychotic types did not make more use of psychiatric services or use more adjuvant medications. The high percentage of patients prescribed a combination may be due to antipsychotic polypharmacy preferences and may represent a very slow crossover from one antipsychotic to another.

Adult↗

PubMed2004

Switching antipsychotics in inpatient schizophrenia care: predictors and outcomes.

BACKGROUND: Within a pharmacoepidemiologic study, characteristics of patients with schizophrenia switched from first- to second-generation antipsychotics (FGAs and SGAs, respectively) or to antipsychotic polypharmacy were compared with those of patients maintained on treatment with FGAs. The primary aim was to assess factors associated with antipsychotic switching and to compare disease course with regard to mental state and social functioning. METHOD: Adult inpatients with an ICD-10 diagnosis of schizophrenia or schizoaffective disorder were assessed in 7 psychiatric hospitals. Data were collected between 2001 and 2002. For those patients (N = 847) with an antipsychotic prescription at discharge, t tests and covariance and logistic regression analyses were used to evaluate the relationship between demographic and clinical characteristics and antipsychotic switching. RESULTS: Patients switched from FGAs to SGAs had fewer previous psychiatric admissions, a shorter illness duration, fewer substance disorders, and a higher probability of working in a competitive setting but more pronounced symptoms than those maintained on treatment with FGAs. Mental state and social functioning after case-mix adjustment were more favorable in the group switched to SGA monotherapy but not in those patients administered FGAs and SGAs concurrently at discharge. Logistic regression controlling for demographic and clinical variables revealed that a short disease duration (p <.05), fewer previous psychiatric hospitalizations (p <.01), voluntary admission (p <.05), and pronounced thought disorder (p <.05) were significantly associated with switching from FGAs to SGAs. Hospital differences were also observed. CONCLUSION: Remaining on FGAs or switching to SGAs in schizophrenia care depends strongly on institutional practices in addition to the previous disease course and health care utilization.

Adult↗