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Carole Caplin alla 13a edizione di ForumClub

Il programma di lotta all’obesità condotta da Regina Benjamin, Surgeon General del governo americano

Publication year: 2011
Source: The American Journal of Geriatric Pharmacotherapy, Available online 16 November 2011

Joseph T. Hanlon, Kenneth E. Schmader

Publication year: 2011
Source: The American Journal of Geriatric Pharmacotherapy, Available online 12 November 2011

Rishi Desai, Charlotte E. Williams, Sandra B. Greene, Stephanie Pierson, Richard A. Hansen

BackgroundPatients transitioning to a nursing home from their home or other facility are at high risk for medication errors.ObjectiveOur aim was to describe characteristics of medication errors occurring during transitions to nursing homes, to compare characteristics of transition errors with errors not involving a transition, and to evaluate the impact of these errors on patient harm.MethodsThis was a cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative during fiscal years 2007 through 2009. Bivariate associations between errors in transition with patient factors, error-related factors, reported causes of errors, and impact on patients were tested using a χtest. Multivariate logistic regression explored whether medication errors during transitions were more harmful than errors not occurring during transitions. Patient-related factors included in the model were age, sex, and cognitive ability. Error-related factors were primary type of error, process phase when error began, primary personnel involved, and an indicator for repeat error.ResultsA total of 27,759 individual medication error incidents were reported over a 3-year period in North Carolina nursing homes. Of these errors, 2919 incidents (11%) involved a patient transitioning to a nursing home. Errors involved in transitions were found to have higher odds of patient harm compared with errors not involved in transitions (odds ratio = 1.85; 95% CI, 1.30–2.63). Staff communication, order transcription, medication availability, pharmacy issues, and name confusion were particularly important contributors to medication errors during transitions (P< 0.05 for comparison with nontransition errors).ConclusionsTransitions across care settings introduce risk for patient harm, and medication errors are an important area for improvement during transitions.

Publication year: 2011
Source: The American Journal of Geriatric Pharmacotherapy, Available online 10 November 2011

Lisa E. Hines, John E. Murphy

BackgroundElderly patients are vulnerable to drug interactions because of age-related physiologic changes, an increased risk for disease associated with aging, and the consequent increase in medication use.ObjectiveThe purpose of this narrative review was to describe findings from rigorously designed observational cohort and case-control studies that have assessed specific drug interactions in elderly patients.MethodsThe PubMed and International Pharmaceutical Abstracts databases were searched for studies published in English over the past 10 years (December 2000–December 2010) using relevant Medical Subject Headings terms (aged; aged, 80 and over;anddrug interactions) and search terms (drug interactionandelderly). Search strategies were saved and repeated through September 2011 to ensure that the most recent relevant published articles were identified. Additional articles were found using a search of review articles and reference lists of the identified studies. Studies were included if they were observational cohort or case-control studies that reported specific adverse drug interactions, included patients aged ≥65 years, and evaluated clinically meaningful end points. Studies were excluded if they used less rigorous observational designs, assessed pharmacokinetic/pharmacodynamic properties, evaluated drug-nutrient or drug-disease interactions or interactions of drug combinations used for therapeutic benefit (eg, dual antiplatelet therapy), or had inconclusive evidence.ResultsSeventeen studies met the inclusion criteria. Sixteen studies reported an elevated risk for hospitalization in older adults associated with adverse drug interactions. The drug interactions included: angiotensin-converting enzyme (ACE) inhibitors and potassium-sparing diuretics, ACE inhibitors or angiotensin receptor blockers and sulfamethoxazole/trimethoprim, benzodiazepines or zolpidem and interacting medications, calcium channel blockers and macrolide antibiotics, digoxin and macrolide antibiotics, lithium and loop diuretics or ACE inhibitors, phenytoin and sulfamethoxazole/trimethoprim, sulfonylureas and antimicrobial agents, theophylline and ciprofloxacin, and warfarin and antimicrobial agents or nonsteroidal anti-inflammatory drugs. One study reported the risk for breast cancer-related death as a function of paroxetine exposure among women treated with tamoxifen.ConclusionsSeveral population-based studies have reported significant harm associated drug interactions in elderly patients. Increased awareness and interventions aimed at reducing exposure and minimizing the risks associated with potentially harmful drug combinations are needed.

Publication year: 2011
Source: The American Journal of Geriatric Pharmacotherapy, Available online 6 November 2011

Emily P. Peron, Shelly L. Gray, Joseph T. Hanlon

BackgroundFunctional status is the cornerstone of geriatric care and serves as an indicator of general well-being. A decline in function can increase health care use, worsen quality of life, threaten independence, and increase the risk of mortality. One of several risk factors for decline in functional status is medication use.ObjectiveOur aim was to critically review published articles that have examined the relationship between medication use and functional status decline in the elderly.MethodsThe MEDLINE and EMBASE databases were searched for English-language articles published from January 1986 to June 2011. Search terms includedaged,humans,drug utilization,polypharmacy,inappropriate prescribing,anticholinergics,psychotropics,antihypertensives,drug burden index,functional status,function change or decline,activities of daily living,gait,mobility limitation, anddisability. A manual search of the reference lists of the identified articles and the authors’ article files, book chapters, and recent reviews was conducted to retrieve additional publications. Only articles that used rigorous observational or interventional designs were included. Cross-sectional studies and case series were excluded from this review.ResultsNineteen studies met the inclusion criteria. Five studies addressed the impact of suboptimal prescribing on function, 3 of which found an increased risk of worse function in community-dwelling subjects receiving polypharmacy. Three of the 4 studies that assessed benzodiazepine use and functional status decline found a statistically significant association. One cohort study identified no relationship between antidepressant use and functional status, whereas a randomized trial found that amitriptyline, but not desipramine or paroxetine, impaired certain measures of gait. Two studies found that increasing anticholinergic burden was associated with worse functional status. In a study of hospitalized rehabilitation patients, users of hypnotics/anxiolytics (eg, phenobarbital, zolpidem) had lower relative Functional Independence Measure motor gains than nonusers. Use of multiple central nervous system (CNS) drugs (using different definitions) was linked to greater declines in self-reported mobility and Short Physical Performance Battery (SPPB) scores in 2 community-based studies. Another study of nursing home patients did not report a significant decrease in SPPB scores in those taking multiple CNS drugs. Finally, 2 studies found mixed effects between antihypertensive use and functional status in the elderly.ConclusionsBenzodiazepines and anticholinergics have been consistently associated with impairments in functional status in the elderly. The relationships between suboptimal prescribing, antidepressants, and antihypertensives and functional status decline were mixed. Further research using established measures and methods is needed to better describe the impact of medication use on functional status in older adults.

Publication year: 2011
Source: The American Journal of Geriatric Pharmacotherapy, Available online 4 November 2011

Ginny D. Crisp, Jena Ivey Burkhart, Denise A. Esserman, Morris Weinberger, Mary T. Roth

BackgroundMedication is one of the most important interventions for improving the health of older adults, yet it has great potential for causing harm. Clinical pharmacists are well positioned to engage in medication assessment and planning. The Individualized Medication Assessment and Planning (iMAP) tool was developed to aid clinical pharmacists in documenting medication-related problems (MRPs) and associated recommendations.ObjectiveThe purpose of our study was to assess the reliability and usability of the iMAP tool in classifying MRPs and associated recommendations in older adults in the ambulatory care setting.MethodsThree cases, representative of older adults seen in an outpatient setting, were developed. Pilot testing was conducted and a “gold standard” key developed. Eight eligible pharmacists consented to participate in the study. They were instructed to read each case, make an assessment of MRPs, formulate a plan, and document the information using the iMAP tool. Inter-rater reliability was assessed for each case, comparing the pharmacists’ identified MRPs and recommendations to the gold standard. Consistency of categorization across reviewers was assessed using the κ statistic or percent agreement.ResultsThe mean κ across the 8 pharmacists in classifying MRPs compared with the gold standard was 0.74 (range, 0.54–1.00) for case 1 and 0.68 (range, 0.36–1.00) for case 2, indicating substantial agreement. For case 3, percent agreement was 63% (range, 40%–100%). The mean κ across the 8 pharmacists when classifying recommendations compared with the gold standard was 0.87 (range, 0.58–1.00) for case 1 and 0.88 (range, 0.75–1.00) for case 2, indicating almost perfect agreement. For case 3, percent agreement was 68% (range, 40%–100%). Clinical pharmacists found the iMAP tool easy to use.ConclusionsThe iMAP tool provides a reliable and standardized approach for clinical pharmacists to use in the ambulatory care setting to classify MRPs and associated recommendations. Future studies will explore the predictive validity of the tool on clinical outcomes such as health care utilization.

Publication year: 2011
Source: The American Journal of Geriatric Pharmacotherapy, Available online 4 November 2011

Bruce W. Bode, Jason Brett, Ali Falahati, Richard E. Pratley

BackgroundManaging elderly patients with type 2 diabetes poses particular challenges, so it is important to evaluate the efficacy and tolerability profile of antidiabetic therapies specifically in this patient population.ObjectiveThe aim of our study was to compare the efficacy and tolerability profile of liraglutide, a GLP-1 analog, in elderly (≥65 years) and younger (<65 years) patients with type 2 diabetes.MethodsA pooled analysis of 6 randomized, placebo-controlled, multinational trials included data from 3967 patients aged18 to 80 years with type 2 diabetes and glycosylated hemoglobin (HbA1c) of 7% to 11%. Of these, 552 patients ≥65 years received liraglutide 1.8 mg, liraglutide 1.2 mg, or placebo; 2231 patients <65 years received liraglutide 1.8 mg, liraglutide 1.2 mg, or placebo for 26 weeks. End points were: change in HbA1c, fasting plasma glucose, body weight, and blood pressure: as marked to identify elements tracked for change from baseline; hypoglycemic episodes; and adverse events.ResultsReduction in HbA1cfrom baseline was significantly greater with liraglutide 1.8 mg versus placebo (least squares mean differen ≥65 years, 0.91% [95% CI, 0.69–1.12]; <65 years, 1.17% [95% CI, 1.06–1.28]; both,P< 0.0001) and with liraglutide 1.2 mg versus placebo (≥65 years, 0.87% [95% CI, 0.64–1.11]; <65 years, 1.10% [95% CI, 0.98–1.22]; both,P< 0.0001). For fasting plasma glucose, comparable results were observed between liraglutide 1.8 mg or 1.2 mg and placebo for both age groups (P< 0.0001). No statistically significant difference in body weight change was seen with liraglutide between the age groups. The proportion of patients reporting minor hypoglycemia was low and appeared comparable between the ≥65-year-old (4.3%–15.2%) and <65-year-old (8%–13.2%) groups. Likewise, adverse events appeared comparable in nature and frequency.ConclusionLiraglutide provides effective glycemic control and is well tolerated in patients ≥65 and <65 years of age with type 2 diabetes. These data suggest that liraglutide may be a suitable treatment option for older patients who may have additional age-related complications.

Publication year: 2011
Source: The American Journal of Geriatric Pharmacotherapy, Available online 4 November 2011

Sunny A. Linnebur, Douglas N. Fish, J. Mark Ruscin, Tiffany A. Radcliff, Kathy S. Oman, …

BackgroundAcademic detailing in nursing homes (NHs) has been shown to improve drug use patterns and adherence to guidelines.ObjectiveThe purpose of this study was to evaluate the impact of a multidisciplinary intervention that included academic detailing on adherence to national nursing home–acquired pneumonia (NHAP) guidelines related to use of antibiotics.MethodsThis quasi-experimental study evaluated the effects of a 2-year multifaceted and multidisciplinary intervention targeting implementation of national evidence-based guidelines for NHAP. Interventions took place in 8 NHs in Colorado; 8 NHs in Kansas and Missouri served as controls. Interventions included (1) educational sessions for nurses to improve recognition and timely treatment of NHAP symptoms and (2) academic detailing to clinicians by pharmacists regarding diagnostic and prescribing practices. Differences in antibiotic use between groups were compared after 2 intervention years relative to baseline.ResultsA total of 549 episodes of NHAP were evaluated in the intervention group and 574 in the control group. Compared with baseline, 1 facility in the intervention group significantly improved in guideline adherence for optimal antibiotic use (P= 0.007), whereas no facilities in the control group improved. The mean adherence score for optimal antibiotic use in intervention NHs increased from 60% to 66%, whereas the control NHs increased from 32% to 39% (P= 0.3). Mean adherence to guidelines recommending antibiotic use within 4 hours of NHAP diagnosis increased from 57% to 75% in intervention NHs but decreased from 38% to 31% in control NHs (P= 0.0003 for difference). There was no difference between intervention and control NHs for guideline adherence regarding optimal duration of antibiotic use.ConclusionsThe ability of this multifaceted study to repeatedly remind nursing staff of the importance of timely antibiotic administration contrasts with its limited academic detailing interaction with clinicians. This difference within the intervention may explain the differential impact of the intervention on antibiotic guideline adherence.

Publication year: 2011
Source: The American Journal of Geriatric Pharmacotherapy, Available online 1 November 2011

Elizabeth Rightmier, Vanessa Stevens, Jack Brown

BackgroundStreptococcus pneumoniaeinfections are a major cause of morbidity and mortality in older adults. Vaccination in older adults is intended to preventS pneumoniaeinfections, yet little information is available regarding its efficacy in this patient population.ObjectiveThe aim of this article was to review the current literature to determine the efficacy and tolerability ofS pneumoniaevaccination in older adults.MethodsPubMed (1950–present) and EMBASE (1974–present) were searched using the search termsStreptococcus pneumoniae immunization, pneumococcus immunization, pneumococcus vaccine,andaged. Additional articles were identified from the reference lists of included studies. Studies were included if they reported information in older (55–<65 years) and elderly (≥65 years) adults and were related to at least 1 of the following topics: epidemiology ofS pneumoniae,estimates of vaccine coverage, recommendations for vaccination, tolerability, and efficacy and/or effectiveness of vaccination againstS pneumoniae.ResultsSix randomized controlled trials and 18 observational studies that evaluated the efficacy of pneumococcal vaccination in older and elderly adults were reviewed. Findings from evaluations of efficacy, as measured by clinical outcomes and immunogenicity, in older adults have been conflicting, with some subsets of prospective, well-controlled studies finding little benefit, whereas findings from several retrospective studies have suggested significant benefit. This discord may have been a result of the limited power of the prospective subanalyses to detect significant differences.ConclusionsIn light of the potential clinical benefit and few reports of serious adverse events, vaccination in older adults is likely warranted. Prospective, well-controlled studies are needed to better quantitatively evaluate the benefit of pneumococcal vaccine in older adults.