ASCP: Ten Key Geriatric Articles

Description: The following articles have been identified as pertinent geriatric literature. Each citation comes complete with a link, abstract, & excerpt(s) which provide a brief summary about each article. Structure: This document is separated into 3 sections based on clinical theme. The clinical themes are: 1. Medication Appropriateness 2. Medication Monitoring & Adverse Drug Events 3. Geriatric Conditions/ Care

Medication Appropriateness: (4 articles)

1. Citation: Steinman, MA, Hanlon JT. Managing Medications in Clinically Complex Elders Theres Got to Be a Happy Medium JAMA 2010;304 (14)1593-1601 Link: www.jama.ama-assn.org/content/304/14/1592.abstract Abstract: Multiple medication use is common in older adults and may ameliorate symptoms, improve and extend quality of life, and occasionally cure disease. Unfortunately, multiple medication use is also a major risk factor for prescribing and adherence problems, adverse drug events, and other adverse health outcomes. Using the case of an older patient taking multiple medications, this article summarizes the evidence-based literature about improving medication use and withdrawing specific drugs and drug classes. It also describes a systematic approach for how health professionals can assess and improve medication regimens to benefit patients and their caregivers and families. Excerpts: The task for the clinician is not to determine whether too many or too few medications are being taken, but to determine if the patient is taking the right medications- tailored to the patients individual circumstances, including his or her constellation of comorbidities, goals of care, preferences, and ability to adhere to medications. Although few data are available about the effect of structured medication management on patient health and well-being, such approaches are endorsed by experts, in part due to clear evidence of beneficial effects on markers of prescribing quality. ***************************************************************************************************** 2. Citation: Huisman-Baron M, van der Veen L, Jansen PA, et al. Criteria for Drug Selection in Frail Elderly Persons. Drugs Aging 2011; 25 (5):391-402. Link: www.ncbi.nlm.nih.gov/pubmed/21542661 Abstract: Background: Elderly patients with multiple morbidities and polypharmacy are at an increased risk of adverse drug events (ADEs). Appropriate prescribing, preserving the balance between drug effectiveness and safety, and treatment adherence may prevent these ADEs. In this study, we investigated which drug properties, such as effectiveness, safety, clinical experience and convenience, are relevant to the choice of medicine most appropriate for frail elderly patients. Objectives: The primary aim of this study was to develop a set of criteria to assist in the selection of the most appropriate drug within a drug class for the treatment of frail elderly patients. A secondary goal was to test the usefulness of the set of criteria in the prescription of antipsychotics for delirium and behavioural and psychological symptoms of dementia (BPSD).

ASCP: Ten Key Geriatric Articles

Methods: Thirty-one criteria potentially relevant to the choice of appropriate drugs for frail elderly patients were selected on the basis of a literature search in MEDLINE (1966-2008), EMBASE (1947-2008) and the Cochrane Library (1993-2008). This list was reviewed by 46 experts (24 physicians, 22 pharmacists), who scored each item for relevance in clinical practice on a scale from 1 to 10 (where 1 is not important and 10 is very important). By consensus, the authors selected the most relevant criteria for the final set of criteria. The usefulness of the final set of criteria was assessed with regard to the prescription of antipsychotics for delirium and BPSD. Results: The final set of 23 items consisted of 3 items on effectiveness, 14 on safety, including pharmacokinetic and pharmacodynamic criteria, 3 on clinical experience and 3 on convenience. Assessment using these criteria of the appropriateness of antipsychotics prescribed for delirium and BPSD revealed that certain drugs should be prescribed with caution to patients with Parkinson's disease and Lewy body dementia. Conclusions: The criteria identified in this study, selected on the basis of a literature review and clinical expert opinion, represent a promising approach for determining the appropriateness of a drug for use in frail elderly individuals relative to alternative drugs for the same indication or from the same class. Excerpts: Criteria reflecting aspects of pharmacotherapy in the frail elderly are needed to make an optimal choice of a drug within a drug class. As far as we know, such criteria have not yet been described in the literature. This evidence and practice-based list proved useful for determining the appropriateness of a single antipsychotic for use in frail elderly patients compared with alternative drugs for the same indication or within the same class. This may be a promising approach for developing a drug formulary. ***************************************************************************************************** 3. Citation: Shrank WH, Polinski JM, Averon J. Quality Indicators for Medication Use in Vulnerable Elders. JAGS. 2007;(55):373-382 Link: www.ncbi.nlm.nih.gov/pubmed/17910560 Abstract: Medications play a critical role in maintaining the health of vulnerable elders (VEs), who often contend with a great burden of acute and chronic illness. Older patients disproportionately use prescription drugs, with seniors filling an average of 20 prescriptions annually, and aging can be associated with decreased metabolism and excretion of prescription drugs and their metabolites, placing elderly patients at greater risk of side effects and complicating appropriate dosing. Additionally, patients, caregivers, and even physicians often mistake medication side effects for the onset of new illnesses or aging itself. The underrepresentation of elderly patients in clinical trials and the resulting deficiencies of useful data to guide practice create additional challenges for prescribers. A careful review of existing evidence can inform clinical practice and can be used to create quality indicators (QIs), with a goal of benchmarking the quality of care provided. In the first iteration of Assessing Care of Vulnerable Elders (ACOVE), indicators were created to measure the quality of care across multiple domains to represent the full continuum of pharmacological care. The attention given to the full continuum of care differentiates ACOVE indicators from other lists that focus on identification of medications that should be avoided in elderly people. A chart-based review of pharmacological care of community-dwelling elderly people in a managed care setting applying indicators from the first ACOVE process found substantial underuse of appropriate medications (50% indicator pass rate). In addition, shortfalls were seen in medication monitoring (64% pass rate) and education (81% pass rate). Overuse of inappropriate medications occurred infrequently (97% passrate), although the measurement set had limited ability to identify deficits in this area. This updated set of QIs reevaluates QIs to assess pharmacological care provided to community-dwelling VEs. The indicators have been updated to reflect recent literature, and new indicators were added in accordance with evidence-based standards.

ASCP: Ten Key Geriatric Articles

Excerpts: ALL VEs should have an up-to-date medication list readily available in the medical record that is accessible to all healthcare providers and includes over-the-counter medications, BECAUSE such a list makes it possible to identify potential drug-related cause of new symptoms, define and eliminate inappropriate duplication of therapies, correct dangerous drug-drug or drug-disease interactions, and streamline the regimen to improve adherence. The quality of pharmacological care is frequently substandard tin the United States, with substantial room for improvement in VEs. By frequently reevaluating the literature to update indicators that can be used to measure appropriate care in older patients, better benchmarking and measurement of quality is possible. Such activity is critical to improve the quality of pharmacological care in VEs. ***************************************************************************************************** 4. Citation: Holmes HM, Hayley DC, Alexander GC, et al. Reconsidering Medication Appropriateness for Patients Late in Life. Arch Intern Med 2006; 166:605-609 Link: http://archinte.ama-assn.org/cgi/content/extract/166/6/605 Abstract: Providing guideline-adherent care for many medical conditions increasingly means the addition of more medications to reach disease-specific targets. When might it be best to withhold or discontinue medications that are otherwise appropriate on the basis of guidelines? Receiving facsimiles from the pharmacy serving a local nursing home encouraging us to prescribe statins for residents there symbolizes the issues. Most of these patients had a limited life expectancy, were older than 90 years, or had advanced dementia. Similar situations occur in patients with functional impairments, frailty, or diseases like emphysema, congestive heart failure, or coronary artery disease in their advanced stages, for whom starting or continuing many recommended drugs does not seem the best way to optimize care. Excerpts: Regardless of standards of care, practice guidelines, and other clinical pathways, shared decision making among physicians, patients and families about goals of care is important when deciding whether to stop, start, or continue therapy with a medicine for a patient late in life. As disease progresses and it is clearer that cure is not realistic, an individualized approach to patient treatment may become increasingly palliative. Our model addresses issues when one considers medication use late in life that are not adequately considered with existing models of medication appropriateness, thus our model could aid in the development of guidelines to reduce polypharmacy in older patient who may have limited life expectancy. *****************************************************************************************************

Medication Monitoring & Adverse Drug Events: (3 articles)

1. Citation: Steinman MA, Handler SM, Gurwitz JH, et al. Beyond the Prescription: Medication Monitoring and Adverse Drug Events in Older Adults. J Am Geriatr Soc 2011;59(8):1513-1520. Link: www.ncbi.nlm.nih.gov/pubmed/21797831 Abstract: Whether a person will suffer harm from a medication or how severe that harm will be is difficult to predict precisely. As a result, many adverse drug events (ADEs) occur in patients in whom it was reasonable to believe that the drug's benefits exceeded its risks. Improving safety and reducing the burden of ADEs in older adults

ASCP: Ten Key Geriatric Articles

requires addressing this uncertainty by not only focusing on the appropriateness of the initial prescribing decision, but also by detecting and mitigating adverse events once they have started to occur. Such enhanced monitoring of signs, symptoms, and laboratory parameters can determine whether an adverse event has only mild and short-term consequences or major long-term effects on morbidity and mortality. Although current medication monitoring practices are often suboptimal, several strategies can be leveraged to improve the quality and outcomes of monitoring. These strategies include using health information technology to link pharmacy and laboratory data, prospective delineation of risk, and patient outreach and activation, all within a framework of team-based approaches to patient management. Although many of these strategies are theoretically possible now, they are poorly used and will be difficult to implement without a significant restructuring of medical practice. An enhanced focus on medication monitoring will also require a new conceptual framework to reengineer the prescribing process. With this approach, prescribing quality does not hinge on static attributes of the initial prescribing decision but entails a dynamic process in which the benefits and harms of drugs are actively monitored, managed, and reassessed over time. Excerpts: This article describes a conceptual framework for considering a more-proactive role in monitoring symptoms, signs, and laboratory parameters for adverse events and suggests approaches to help overcome current problems in monitoring practices. There is no single best solution. The evidence base is insufficiently robust to allow direct comparisons, and the effectiveness of any given strategy is highly dependent on local conditions, including the ability to piggyback monitoring interventions onto existing, broad-based programs. Thus, the choice of which strategy will yield the most value for any given office practice, institution, or healthcare system will depend on local circumstances, incentives, and identification of areas where there is readiness for change. ***************************************************************************************************** 2. Citation: Field TS, Mazor KM, Briesacher B, et al. Adverse Drug Events Resulting from Practice Errors in Older Adults. J. Am Geriatric Soc. 2007 (55) 271-276 Link: http://www.ncbi.nlm.nih.gov/pubmed/17302666 Abstract: Objectives: To characterize the types of patient-related errors that lead to adverse drug events (ADEs) and identify patients at high risk of such errors. Design: A subanalysis within a cohort study of Medicare enrollees. Setting: A large multispecialty group practice. Participants: Thirty thousand Medicare enrollees followed over a 12-month period. Measurements: Primary outcomes were ADEs, defined as injuries due to a medication, and potential ADEs, defined as medication errors with the potential to cause an injury. The subset of these events that were related to patient errors was identified. Results: The majority of patient errors leading to adverse events (n=129) occurred in administering the medication (31.8%), modifying the medication regimen (41.9%), or not following clinical advice about medication use (21.7%). Patient-related errors most often involved hypoglycemic medications (28.7%), cardiovascular medications (21.7%), anticoagulants (18.6%), or diuretics (10.1%). Patients with medication errors did not differ from a comparison group in age or sex but were taking more regularly scheduled medications (compared with 0-2 medications, odds ratio (OR) for 3-4 medications=2.0, 95% confidence interval (CI)=0.9-4.2; OR for 5-6 medications=3.1, 95% CI=1.5-7.0; OR for >or=7 medications=3.3, 95% CI=1.5-7.0). The strongest association was with the Charlson Comorbidity Index (compared with a score of 0, OR for a score of 1-2=3.8, 95% CI=2.1-7.0; OR for a score of 3-4=8.6, 95% CI=4.3-17.0; OR for a score of >or=5=15.0, 95% CI=6.534.5). Conclusion:

ASCP: Ten Key Geriatric Articles

The medication regimens of older adults present a range of difficulties with the potential for harm. Strategies are needed that specifically address the management of complex drug regimens. Excerpts: Previous studies have developed categories of patient misunderstandings of medication directions and patient medication errors, but no previous literature categorizing the activities involved in patients handling of their medications could be defined. Issues that have been identified in the literature as increasing the complexity of prescribed regimens include medications with conflicting administration patterns, frequent changes in administration schedules, the inclusion of as-needed drugs and those for which dose and frequency are based on patient monitoring, and medication handling that produces disruptions in patients lifestyles. ***************************************************************************************************** 3. Citation: Bundnitz DS, Shehab N, Keglet SR, et al. Medication Use leading to Emergency Department Visits for Adverse Drug Events in Older Adults. Ann Intern Med 2007;147:755-765 Link: www.annals.org/content/147/11/755 Abstract: Background: The Beers criteria identify inappropriate use of medications in older adults. The number of and risk for adverse events from these medications are unknown. Objective: To estimate the number of and risk for emergency department visits for adverse events involving Beers criteria medications compared with other medications. Design: Nationally representative, public health surveillance of adverse drug events and a cross-sectional survey of outpatient medical visits. Setting: National Electronic Injury Surveillance SystemCooperative Adverse Drug Event Surveillance System, 20042005; National Ambulatory Medical Care Survey, 2004; and National Hospital Ambulatory Medical Care Survey, 2004. Participants: Persons 65 years of age or older seeking emergency department and outpatient care. Measurements: Estimated number of and risks for emergency department visits for adverse drug events involving Beers criteria medications and other medications. Results: Among U.S. patients 65 years of age or older, an estimated 177 504 emergency department visits (95% CI, 100 155 to 254 854 visits) for adverse drug events occurred both years. An estimated 3.6% (CI, 2.8% to 4.5%) of these visits were for adverse events medications considered to be always potentially inappropriate, according to the Beers criteria, and 33.3% (CI, 27.8% to 38.7%) of visits were for adverse events from 3 other medications (warfarin [17.3%], insulin [13.0%], and digoxin [3.2%]). Accounting for outpatient prescription frequency, the risk for emergency department visits for adverse events due to these 3 medications was 35 times (CI, 9.6 to 61) greater than that for medications considered to be always potentially inappropriate. Limitation: Adverse events were identified only in emergency departments. Conclusion: Compared with other medications, Beers criteria medications caused low numbers of and few risks for emergency department visits for adverse events. Performance measures and interventions targeting warfarin, insulin, and digoxin use could prevent more emergency department visits for adverse events. Excerpts: The Beers criteria have received renewed attention as a quality and safety measure because prescription data can be easily collected using administrative sources, and substituting a superior medication for an inferior is an elegant clinical intervention.

ASCP: Ten Key Geriatric Articles

Clinicians should continue to use criteria of medication appropriateness to optimize medication selection for their older patients. However, these national public health surveillance and data suggest that there may be considerable opportunity to reduce adverse events in the older patients through interventions that improve the use of anticoagulants, antidiabetic agents, and narrow therapeutic index medications. *****************************************************************************************************

Geriatric Conditions/Care: (3 articles)

1. Citation: OMahony D, OConnor MN. Pharmacotherapy at the end-of-life. Age and Ageing. 2011; (4) 419-422. Link: http://ageing.oxfordjournals.org/content/40/4/419.abstract Abstract: Older people reaching end-of-life status are particularly at risk from inter-related adverse effects of pharmacotherapy, including polypharmacy, inappropriate medications and adverse drug events. These adverse effects of pharmacotherapy may be highly detrimental, as well as highly expensive. End-of-life pharmacotherapy is sometimes perceived to be complex and challenging, probably unnecessarily. This relates in part to the poorly developed evidence base and lack of high-quality research in this area. In this article, we deal with some of the key issues relating to pharmacotherapy in end-of-life patients, namely (i) the guiding principles of drug selection, (ii) the main drugs and drug classes that are best avoided, (iii) the benefits of oligopharmacy (i.e. deliberate avoidance of polypharmacy) in end-of-life patients. Excerpts: Although frailer, older people are usually excluded from randomized controlled trials, prescribers often persist with evidence-based prescribing in end-of-life older patients. In turn, this evidence-based approach of prescribing for all treatable medical conditions is unnecessarily expensive and ultimately of dubious benefit to the patient. Most older people reach end-of-life status having been prescribed medicines for a variety of chronic medical conditions and polypharmacy is commonplace, even in patients with advanced dementia. Identification of endof-life should bring about a significant reduction in the number of daily drugs. ***************************************************************************************************** 2. Citation: Hanlon JT, Aspinall SL, Semla TP, et al. Consensus Guidelines for Oral Dosing of Primarily Really Cleared Medications in Older Adults. J Am Geriatr Soc 2009; 57 (2):335-340 Link: www.ncbi.nlm.nih.gov/pubmed/19170784 Abstract: Objectives: To establish consensus oral dosing guidelines for primarily renally cleared medications prescribed for older adults. Design: Literature search followed by a two-round modified Delphi survey. Setting: A nationally representative survey of experts in geriatric clinical pharmacy. Participants: Eleven geriatric clinical pharmacists. Measurements: After a comprehensive literature search and review by an investigative group of six physicians (2 general internal medicine, 2 nephrology, 2 geriatrics), 43 dosing recommendations for 30 medications at various levels of renal function were created. The expert panel rated its agreement with each of these 43 dosing recommendations using a 5-point Likert scale (1=strongly disagree to 5=strongly agree). Recommendation-

ASCP: Ten Key Geriatric Articles

specific means and 95% confidence intervals were estimated. Consensus was defined as a lower 95% confidence limit of greater than 4.0 for the recommendation-specific mean score. Results: The response rate was 81.8% (9/11) for the first round. All respondents who completed the first round also completed the second round. The expert panel reached consensus on 26 recommendations involving 18 (60%) medications. For 10 medications (chlorpropamide, colchicine, cotrimoxazole, glyburide, meperidine, nitrofurantoin, probenecid, propoxyphene, spironolactone, and triamterene), the consensus recommendation was not to use the medication in older adults below a specified level of renal function (e.g., creatinine clearance <30 mL/min). For the remaining eight medications (acyclovir, amantadine, ciprofloxacin, gabapentin, memantine, ranitidine, rimantadine, and valacyclovir), specific recommendations for dose reduction or interval extension were made. Conclusion: An expert panel of geriatric clinical pharmacists was able to reach consensus agreement on a number of oral medications that are primarily renally cleared. Excerpts: Medications are the most frequently used therapy for the management of problems in older adults. Unfortunately, these same medications are often prescribed at inappropriate doses. Studies have shown that up to two-thirds of older patients receive inappropriately high doses of primarily renally cleared medications. This study found that expert geriatric clinical pharmacists could achieve consensus agreement with dosing recommendations for the majority (60%) of a list of primarily renally cleared oral medications commonly used by older adults. ***************************************************************************************************** 3. Citation: Cigolle C. Langa K. Kabeto M. et al. Geriatric Conditions and Disability: The Health and Retirement Study. Ann Intern Med. 2007;147:156-164 Link: http://www.annals.org/content/147/3/156.abstract Abstract: Background: Geriatric conditions, such as incontinence and falling, are not part of the traditional disease model of medicine and may be overlooked in the care of older adults. The prevalence of geriatric conditions and their effect on health and disability in older adults has not been investigated in population-based samples. Objective: To investigate the prevalence of geriatric conditions and their association with dependency in activities of daily living by using nationally representative data. Design: Cross-sectional analysis. Setting: Health and Retirement Study survey administered in 2000. Participants: Adults age 65 years or older (n = 11 093, representing 34.5 million older Americans) living in the community and in nursing homes. Measurements: Geriatric conditions (cognitive impairment, falls, incontinence, low body mass index, dizziness, vision impairment, hearing impairment) and dependency in activities of daily living (bathing, dressing, eating, transferring, toileting). Results: Of adults age 65 years or older, 49.9% had 1 or more geriatric conditions. Some conditions were as prevalent as common chronic diseases, such as heart disease and diabetes. The association between geriatric conditions and dependency in activities of daily living was strong and significant, even after adjustment for demographic characteristics and chronic diseases (adjusted risk ratio, 2.1 [95% CI, 1.9 to 2.4] for 1 geriatric condition, 3.6 [CI, 3.1 to 4.1] for 2 conditions, and 6.6 [CI, 5.6 to 7.6] for 3 conditions). Limitations:

ASCP: Ten Key Geriatric Articles

The study was cross-sectional and based on self-reported data. Because measures were limited by the survey questions, important conditions, such as delirium and frailty, were not assessed. Survival biases may influence the estimates. Conclusions: Geriatric conditions are similar in prevalence to chronic diseases in older adults and in some cases are as strongly associated with disability. The findings suggest that geriatric conditions, although not a target of current models of health care, are important to the health and function of older adults and should be addressed in their care. Excerpts: Most older adults with geriatric conditions live in the community and are not under the primary care of a geriatrician. An approach to their care that includes the identification and management of geriatric conditions is needed. This is the first study to use data to quantify the prevalence of geriatric conditions among older adults and to demonstrate that these conditions increase in frequency with age. The high prevalence of geriatric conditions and the strength of their association with ADL dependency demonstrate that these conditions go largely unrecognized in the current disease-based model of clinical care. *****************************************************************************************************

October 20, 2011