Year in review: medication mishaps in the elderly.

Am J Geriatr Pharmacother. 2011 Feb;9(1):1-10

Authors: Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM

Abstract
OBJECTIVE: This paper reviews articles from 2010 that examined medication mishaps (ie, medication errors and adverse drug events [ADEs]) in the elderly.
METHODS: The MEDLINE and EMBASE databases were searched for English-language articles published in 2010 using a combination of search terms including medication errors, medication adherence, medication compliance, suboptimal prescribing, monitoring, adverse drug events, adverse drug withdrawal events, therapeutic failures, and aged. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional publications. Five studies of note were selected for annotation and critique. From the literature search, this paper also generated a selected bibliography of manuscripts published in 2010 (excluding those previously published in the American Journal of Geriatric Pharmacotherapy or by one of the authors) that address various types of medication errors and ADEs in the elderly.
RESULTS: Three studies focused on types of medication errors. One study examined underuse (due to prescribing) as a type of medication error. This before-and-after study from the Netherlands reported that those who received comprehensive geriatric assessments had a reduction in the rate of undertreatment of chronic conditions by over one third (from 32.9% to 22.3%, P < 0.05). A second study focused on reducing medication errors due to the prescribing of potentially inappropriate medications. This quasi-experimental study found that a computerized provider order entry clinical decision support system decreased the number of potentially inappropriate medications ordered for patients ? 65 years of age who were hospitalized (11.56 before to 9.94 orders per day after, P < 0.001). The third medication error study was a cross-sectional phone survey of managed-care elders, which found that more blacks than whites had low antihypertensive medication adherence as per a self-reported measure (18.4% vs 12.3%, respectively; P < 0.001). Moreover, blacks used more complementary and alternative medicine (CAM) than whites for the treatment of hypertension (30.5% vs 24.7%, respectively; P = 0.005). In multivariable analyses stratified by race, blacks who used CAM were more likely than those who did not to have low antihypertensive medication adherence (prevalence rate ratio = 1.56; 95% CI, 1.14-2.15; P = 0.006). The remaining two studies addressed some form of medication-related adverse patient events. A case-control study of Medicare Advantage patients revealed for the first time that the use of skeletal muscle relaxants was associated significantly with an increased fracture risk (adjusted odds ratio = 1.40; 95% CI, 1.15-1.72; P < 0.001). This increased risk was even more pronounced with the concomitant use of benzodiazepines. Finally, a randomized controlled trial across 16 centers in France used a 1-week educational intervention about high-risk medications and ADEs directed at rehabilitation health care teams. Results indicated that the rate of ADEs in the intervention group was lower than that in the usual care group (22% vs 36%, respectively, P = 0.004).
CONCLUSION: Information from these studies may advance health professionals' understanding of medication errors and ADEs and may help guide research and clinical practices in years to come.

PMID: 21459304 [PubMed - indexed for MEDLINE]

Medication reconciliation: identifying medication discrepancies in acutely ill hospitalized older adults.

Am J Geriatr Pharmacother. 2011 Oct;9(5):339-44

Authors: Villanyi D, Fok M, Wong RY

Abstract
BACKGROUND: Medication discrepancies may occur during transitions from community to acute care hospitals. The elderly are at risk for such discrepancies due to multiple comorbidities and complex medication regimens. Medication reconciliation involves verifying medication use and identifying and rectifying discrepancies.
OBJECTIVE: The aim of this study was to describe the prevalences and types of medication discrepancies in acutely ill older patients.
METHODS: Patients who were ? 70 years and were admitted to any of 3 acute care for elders (ACE) units over a period of 2 nonconsecutive months in 2008 were prospectively enrolled. Medication discrepancies were classified as intentional, undocumented intentional, and unintentional. Unintentional medication discrepancies were classified by a blinded rater for potential to harm. This study was primarily qualitative, and descriptive (univariate) statistics are presented.
RESULTS: Sixty-seven patients (42 women; mean [SD] age, 84.0 [6.5] years) were enrolled. There were 37 unintentional prescription-medication discrepancies in 27 patients (40.3%) and 43 unintentional over-the-counter (OTC) medication discrepancies in 19 patients (28.4%), which translates to Medication Reconciliation Success Index (MRSI) of 89% for prescription medications and 59% for OTC medications. The overall MRSI was 83%. More than half of the prescription-medication discrepancies (56.8%) were classified as potentially causing moderate/severe discomfort or clinical deterioration.
CONCLUSION: Despite a fairly high overall MRSI in these patients admitted to ACE units, a substantial proportion of the prescription-medication discrepancies were associated with potential harm.

PMID: 21890424 [PubMed - indexed for MEDLINE]

Medication Discrepancies Identified at Time of Hospital Discharge in a Geriatric Population.

Am J Geriatr Pharmacother. 2011 Jul 13;

Authors: Stitt DM, Elliott DP, Thompson SN

Background: It has been reported that 14.1% of geriatric patients experience ?1 medication discrepancies after hospitalization. OBJECTIVE: The goal of this study was to identify and characterize discharge medication list discrepancies among geriatric patients and to describe characteristics associated with discrepancies. METHODS: An institutional review board-approved retrospective review was conducted of patients aged ?65 years discharged from hospitalist and internal medicine services at a large tertiary care hospital from August 2008 to December 2009. A random cohort of 200 patients was selected and categorized by age, gender, attending medical service, and the absence or presence of a pharmacist on the service. Medication lists were obtained from physician discharge summaries, discharge orders, and nursing discharge lists. RESULTS: A total of 1923 medication discrepancies were identified, consisting of 402 related to the absence or presence of a medication, 298 related to the dosage administered at one time, 223 related to the number of daily doses, and 1000 related to the route of administration. Physician discharge summaries contained the most medication discrepancies. There was no relationship between patient age and the number of medication discrepancies (r(2) = 0.006; P = 0.279), whereas there was a linear relationship between the number of medications and the number of discrepancies (r(2) = 0.249; P < 0.001). The internal medicine team with a pharmacist had a lower average number of discrepancies per patient compared with other medicine services that did not have a pharmacist present. CONCLUSIONS: Medication discrepancies at the time of hospital discharge are a common occurrence for geriatric patients. Physician summaries might be the least reliable source of discharge medication lists. The number of discrepancies appears to not be associated with patient age, but rather with the number of medications at discharge. Discrepancies among medication lists are common, and the presence of a pharmacist may reduce the number that occur.

PMID: 21763215 [PubMed - as supplied by publisher]

Efficacy and safety profile of a single dose of hydromorphone compared with morphine in older adults with acute, severe pain: a prospective, randomized, double-blind clinical trial.

Am J Geriatr Pharmacother. 2009 Feb;7(1):1-10

Authors: Chang AK, Bijur PE, Baccelieri A, Gallagher EJ

BACKGROUND: Older adults (ie, those aged > or =65 years) are the fastest growing segment of the US population, with an estimated approximately 71 million expected by 2030. Over the past 10 years, there has been an 11% increase in the number of emergency department (ED) visits by older adults, and pain is their most common chief complaint. OBJECTIVE: The goal of this study was to compare weight-based IV hydromorphone and IV morphine in adults aged > or =65 years presenting to the ED with acute, severe pain. METHODS: This was a prospective, randomized, double-blind clinical trial of older adults with acute, severe pain at an adult, urban academic ED. Patients were randomly allocated to receive a single dose of 0.0075-mg/kg IV hydromorphone or 0.05-mg/kg IV morphine. The primary outcome was the between-group difference in decrease in pain from baseline to 30 minutes after the medications were infused. Patients' degree of pain was measured on a numerical rating scale (NRS) where "0" was defined as "no pain" and "10" was defined as "the worst pain possible." Adverse effects, pain reduction at 10 minutes and 2 hours postbaseline, patient evaluations of satisfaction and pain relief at 30 minutes postbaseline, and use of additional analgesics and antiemetics were tracked as secondary outcomes. RESULTS: A total of 194 patients were randomized to treatment; 183 patients (hydromorphone group, n = 93; morphine group, n = 90 [overall mean (SD) age, 75 (8) years]) had sufficient data for analysis at the primary end point of 30 minutes postbaseline. The mean decrease in pain from baseline to 30 minutes in patients allocated to IV hydromorphone was 3.8 versus 3.3 NRS units in patients allocated to IV morphine. This difference of 0.5 NRS unit (95% CI, -0.2 to 1.3) was neither clinically nor statistically significant. A majority of patients in both groups (57.0% randomized to hydromorphone and 58.9% randomized to morphine) failed to achieve a > or =50% reduction in pain within 30 minutes of treatment. The incidence of adverse effects from baseline to 30 minutes was not statistically different in the 2 groups. CONCLUSIONS: A single dose of IV hydromorphone at 0.0075 mg/kg was neither clinically nor statistically different from IV morphine at 0.05 mg/kg for the treatment of acute, severe pain at 30 minutes postbaseline in these older adults in the ED. The incidence of adverse effects was not statistically different. Our data suggest that hydromorphone and morphine in the doses given had similar efficacy and safety profiles in these older adults. Neither regimen provided > or =50% pain relief for the majority of patients. Future investigations of acute pain management in older adults should examine the efficacy and safety of higher initial (loading) doses of opioids titrated at frequent intervals until adequate analgesia is achieved.

PMID: 19281935 [PubMed - indexed for MEDLINE]

Appropriate proton pump inhibitor use among older adults: a retrospective chart review.

Am J Geriatr Pharmacother. 2008 Dec;6(5):249-54

Authors: George CJ, Korc B, Ross JS

BACKGROUND: Proton pump inhibitors (PPIs) are widely used, but not always with a clear indication. Nonindicated use is of particular concern among older adults, who may have multiple comorbidities and take more medications, increasing their risk for adverse drug reactions. OBJECTIVE: This study examined the appropriateness of PPI use at an outpatient geriatric practice and the association between particular patient characteristics and appropriate use of these medications. METHODS: This was a retrospective chart review of a group of randomly identified community-dwelling adults aged >or=65 years with a current prescription for a PPI (as of August 2006) from a geriatric ambulatory care practice within an urban academic medical center. The main outcome was appropriateness of PPI use, categorized as indicated, possibly indicated, or not indicated, based on US Food and Drug Administration-approved indications and national gastroenterology guidelines. RESULTS: Out of approximately 2500 patients in the geriatric practice, 702 (approximately 28%) were identified as having a current prescription for a PPI. From these, 110 charts were randomly selected for review, of which 10 were excluded based on predefined criteria. The sample was 79% female and 46% white, with a mean age of 82.8 years (range, 66-99 years). PPI use was indicated in 64% of these patients, possibly indicated in 7%, and not indicated in 29%. Compared with indicated PPI use, nonindicated use was significantly associated with use for <1 year (relative risk = 2.20; 95% CI, 1.00-4.86; P = 0.05). Nonindicated PPI use was not significantly associated with age, female sex, nonwhite race, or PPI initiation in the inpatient setting. CONCLUSION: Almost 30% of patients receiving a PPI in this academic geriatric practice had no documented indication for PPI use.

PMID: 19161927 [PubMed - indexed for MEDLINE]

Megestrol acetate-associated adrenal insufficiency.

Am J Geriatr Pharmacother. 2008 Aug;6(3):167-72

Authors: Bulchandani D, Nachnani J, Amin A, May J

BACKGROUND: Megestrol acetate (MA) is commonly used to promote weight gain in malnourished elderly patients. Although adrenal insufficiency has been reported as an adverse effect of MA, this association is not well recognized in clinical practice. CASE SUMMARY: An 80-year-old woman with worsening dyspnea was transferred to our university-affiliated community medical center from an inpatient psychiatric facility, where she was being treated for major depressive disorder with psychotic features. She had undergone a general decline in physical function accompanied by some weight loss and anorexia consistent with failure to thrive and, 1 month earlier, had been started on MA 400 mg/d to stimulate her appetite and improve her nutrition. During hospitalization at our center, the patient's dyspnea worsened and she was transferred to the intensive care unit, where she was intubated. While in the intensive care unit, the patient developed hypotension. Infectious, cardiac, and neurologic causes of hypotension having been ruled out, a cosyntropin stimulation test was performed to rule out adrenal insufficiency. Cortisol levels before, 30 minutes after, and 60 minutes after administration of cosyntropin were 1.6, 7.1, and 9.8 microg/dL, respectively, indicating a suboptimal response. The adrenocorticotropic hormone level was 8 pg/mL (normal, 10-60 pg/mL). Based on these findings suggesting adrenal insufficiency, MA was discontinued and steroid replacement was initiated. The patient's blood pressure normalized and she improved slowly. She was weaned from the ventilator several weeks later and was discharged to a skilled nursing facility. At 2-month follow-up, the patient's strength and respiratory function were improved, and the results of a repeat cosyntropin stimulation test were normal (cortisol response before, 30 minutes after, and 60 minutes after cosyntropin administration: 15.4, 22.6, and 25.2 microg/dL, respectively). The Naranjo score for this case was 7, indicating a probable correlation between MA use and adrenal insufficiency. CONCLUSIONS: This case of adrenal insufficiency in an elderly woman was probably related to MA use. Clinicians should be alert to the possibility of this adverse effect when considering use of MA therapy.

PMID: 18775392 [PubMed - indexed for MEDLINE]

Effect of darbepoetin alfa administered once monthly on maintaining hemoglobin levels in older patients with chronic kidney disease.

Am J Geriatr Pharmacother. 2008 Jun;6(2):49-60

Authors: Silver MR, Agarwal A, Krause M, Lei L, Stehman-Breen C

BACKGROUND: The anemia of chronic kidney disease (CKD) is associated with increased hospitalizations, increased cardiovascular morbidity and mortality, and diminished quality of life in the elderly. Darbepoetin alfa is an erythropoiesis-stimulating agent that has been shown to be effective in treating anemia in patients with CKD (but not on dialysis) when administered using extended-dosing regimens. OBJECTIVE: The purpose of this post hoc analysis was to examine the efficacy and safety profile of once-monthly (QM) darbepoetin alfa in study patients stratified according to age (ie, <65, 65-74, and > or =75 years). METHODS: Patients with CKD but not on dialysis, receiving darbepoetin alfa every other week (Q2W), and with stable hemoglobin (Hb) levels between 11 and 13 g/dL, inclusive, were enrolled in this 33-week, multicenter, open-label, single-arm study. The study was carried out at 36 US centers and consisted of a 24-week QM darbepoetin alfa dose-titration period followed by an 8-week evaluation period. Hb levels were measured Q2W. Study results were stratified according to patient age (<65, 65-74, and > or =75 years). RESULTS: A total of 152 patients (79 women, 73 men) were enrolled; 55 patients (36%) were <65 years of age, 46 (30%) were 65 to 74 years of age, and 51 (34%) were > or =75 years of age. In patients who received > or =1 dose of darbepoetin alfa, Hb levels > or =11 g/dL were maintained in 76%, 80%, and 71% of patients aged <65, 65 to 74, and > or =75 years, respectively. For patients who completed the study, the proportions who maintained Hb levels > or =11 g/dL were 83%, 88%, and 85%, respectively, for the 3 age groups. The safety profile of QM darbepoetin alfa in this study was consistent with that expected in patients with CKD not receiving dialysis. CONCLUSIONS: Darbepoetin alfa administered QM maintained Hb levels > or =11 g/dL in patients with CKD (not on dialysis) aged <65, 65 to 74, and > or =75 years. This treatment regimen may help optimize anemia management for older community-dwelling and long-term care patients.

PMID: 18675764 [PubMed - indexed for MEDLINE]

Polypharmacy in elderly patients.

Am J Geriatr Pharmacother. 2007 Dec;5(4):345-51

Authors: Hajjar ER, Cafiero AC, Hanlon JT

BACKGROUND: Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly. OBJECTIVE: The goal of this research was to provide a description of observational studies examining the epidemiology of polypharmacy and to review randomized controlled studies that have been published in the past 2 decades designed to reduce polypharmacy in older adults. METHODS: Materials for this review were gathered from a search of the MEDLINE database (1986-June 2007) and International Pharmaceutical Abstracts (1986-June 2007) to identify articles in people aged >65 years. We used a combination of the following search terms: polypharmacy, multiple medications, polymedicine, elderly, geriatric, and aged. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that measured polypharmacy. RESULTS: The literature review found that polypharmacy continues to increase and is a known risk factor for important morbidity and mortality. There are few rigorously designed intervention studies that have been shown to reduce unnecessary polypharmacy in older adults. The literature review identified 5 articles, which are included here. All studies showed an improvement in polypharmacy. CONCLUSIONS: Many studies have found that various numbers of medications are associated with negative health outcomes, but more research is needed to further delineate the consequences associated with unnecessary drug use in elderly patients. Health care professionals should be aware of the risks and fully evaluate all medications at each patient visit to prevent polypharmacy from occurring.

PMID: 18179993 [PubMed - indexed for MEDLINE]

Pharmacologic prevention of aspiration pneumonia: a systematic review.

Am J Geriatr Pharmacother. 2007 Dec;5(4):352-62

Authors: El Solh AA, Saliba R

BACKGROUND: Aspiration pneumonia is a common cause of morbidity and mortality. Several approaches, including bed positioning, dietary changes, and oral hygiene, have been proposed to prevent aspiration pneumonia, yet few data are available on the efficacy of pharmacologic interventions in reducing the rate of aspiration. OBJECTIVE: This study was a systematic literature review of the pharmacologic prevention of aspiration pneumonia. METHODS: We searched MEDLINE (1996-2006); EMBASE (1974-2006); Cumulative Index to Nursing & Allied Health Literature (CINAHL) (1982-2006); Health Services Technology, Administration, and Research (HealthSTAR) (1975-2006); and the Cochrane Library for relevant articles. References of all included articles were reviewed. Studies were included if they had a prospective, controlled design with a primary outcome of prevention of aspiration pneumonia. Surrogate outcomes that had a direct link to decreasing the incidence of aspiration pneumonia were considered. Selected articles were reviewed independently by 2 authors. RESULTS: Of 1108 studies reviewed, 20 were analyzed. Angiotensin-converting enzyme inhibitors may be beneficial in selected patients at high risk for aspiration. Capsaicin may be a low-risk approach to stimulate swallowing and cough reflexes. Amantadine, cabergoline, and theophylline may cause serious adverse events, and their routine use for prevention of aspiration pneumonia is not recommended. Cilostazol should not be used because of the increased risk for bleeding. CONCLUSIONS: Limited information is available on benefits and risks to guide an evidence-based approach to the pharmacologic prevention of aspiration pneumonia. Considering the high incidence of aspiration pneumonia in older adults, large randomized clinical trials on the effectiveness of pharmacologic interventions are warranted.

PMID: 18179994 [PubMed - indexed for MEDLINE]