Complexities of care: Common components of models of care in geriatrics.

As people age, they are more likely to have an increasing number of medical diagnoses and medications, as well as healthcare providers who care for those conditions. Health professionals caring for older adults understand that medical issues are not the sole factors in the phenomenon of this "care complexity." Socioeconomic, cognitive, functional, and organizational factors play a significant role. Care complexity also affects family caregivers, providers, and healthcare systems and therefore society at large. The American Geriatrics Society (AGS) created a work group to review care to identify the most common components of existing healthcare models that address care complexity in older adults. This article, a product of that work group, defines care complexity in older adults, reviews healthcare models and those most common components within them and identifies potential gaps that require attention to reduce the burden of care complexity in older adults.

Change in Medication-Associated Fall Risk Among Older Adults After Admission for Fall-Related Trauma.

BACKGROUND: As the population ages, it is predicted that approximately 40% of all patients who experience fall-related trauma will be 65 years of age and older. Most injuries in older adults are caused by falls that are the result of multiple contributing factors including home hazards, comorbidities, frailty, and medications. A variety of medications have been associated with falls, specifically those with sedating and anticholinergic effects. The drug burden index can be used to quantify sedating and anticholinergic drug burden, with higher scores being associated with reduced psychomotor function. OBJECTIVE: Assess the medication-associated fall risk on admission and discharge for older patients admitted to a trauma nurse practitioner service. METHODS: Retrospective, observational study of patients managed by trauma nurse practitioners at a Level 1 trauma center between January 1, 2018, and December 31, 2019. Patients were included if they were at least 65 years of age, the primary diagnosis for the admission was fall-related trauma, and length of stay was at least 7 days. RESULTS: A total of 172 patients were included in the study. The drug burden index was significantly higher at discharge than admission (M = 1.4, SD = 0.9 vs. M = 1.9, SD = 0.9) as was the total number of medications (M = 11.0, SD = 5.2 vs. M = 15.1, SD = 5.8). CONCLUSIONS: Medication-related fall risk was increased during admission due to fall-related trauma. Patients were discharged with a higher sedating and anticholinergic burden than on admission, which increases risk for future falls.

Osteoarthritis in Older Adults: Nonsteroidal Anti-Inflammatory Drugs Versus Opioids.

Persistent pain in older adults as a result of osteoarthritis (OA) has various treatment options, and all of them have significant risks. An oral nonsteroidal anti-inflammatory drug (NSAID) or an opioid can be considered as a treatment option when persistent pain is not controlled by nonpharmacological interventions and regularly scheduled doses of acetaminophen. However, NSAIDs are nephrotoxic and may cause upper gastrointestinal bleeding. These risks can be mitigated through the initiation of a proton-pump inhibitor and careful monitoring of renal function and serum electrolytes. A low-dose opioid taken as needed can be considered as a treatment option if the pain is not controlled by NSAIDs as long as the risks associated with central nervous system depression and dose escalation as a result of tolerance are monitored closely. The complete patient profile must be taken into consideration when determining the best option.

Social Work's Participation in the Geriatric Education Centers Educational Evaluation: A Brief Report.

This study was conducted to determine the level and types of participation of social workers in the activities of the Geriatric Education Centers (GECs). Through an online survey of GECs, the level of participation of social work professionals was compared with those in dentistry, nursing, medicine, and pharmacy, during the years 2010 to 2014. Thirty-one percent (14) of the 45 GECs completed the survey. The results found increases in participation for both social workers and nurses for both GEC activities and involvement in leadership positions within the centers. The GECs also identified caregiver and provider education and continuing education as activities in which social workers have had an increased interest in recent years. Implications from this study can inform the programming efforts of the new Geriatric Workforce Enhancement Program (GWEP) and other geriatric education programs.

Evaluating the Evidence Behind Treating Osteoporosis in the Oldest Adults.

OBJECTIVE: To review clinical trial data supporting the use of drugs to treat osteoporosis in the oldest adults, 74 years of age and older. DATA SOURCES: The PubMed database (September 1969-June 2017) was searched utilizing the following Medical Subject Headings terms: osteoporosis, postmenopausal, aged, 80 and over, and fractures, bone, in combination with diphosphonates, denosumab, parathyroid hormone, raloxifene, and calcitonin. STUDY SELECTION/DATA EXTRACTION: An initial search revealed 119 results, of which 18 clinical trials were included. Studies were selected that featured a randomized controlled design, fractures reported as a key outcome, and included subjects within the desired age range. DATA SYNTHESIS: Osteoporosis is common among older adults, and with an increasingly aging population, it will be imperative to know how to best manage this condition. Sparse clinical evidence exists for the impact of osteoporosis treatments in the given age range, and no clinical trials have exclusively looked at this age group as the primary target. CONCLUSION: Studies that included participants in this age group were found for alendronate, risedronate, zoledronic acid, denosumab, teriparatide, and abaloparatide. Efficacy appears to be maintained with advancing age for alendronate, zoledronic acid, denosumab, and teriparatide as demonstrated by post hoc analyses of pivotal trials. Alendronate has only demonstrated benefit in patients with previous vertebral fractures because of the study design of the trial. Abaloparatide showed improvement with treatment in the overall population, but age-specific analyses have not been published at this time.

Topical Metronidazole for Odor Control in Pressure Ulcers.

There are many remedies that have been recommended for the treatment of foul odor associated with pressure ulcers. This article seeks to review the literature surrounding the use of metronidazole as a safe and effective solution to an oftentimes stubborn and frustrating problem. Other tools used to control odor include bleach-based solutions and charcoal dressings. Metronidazole, with its antianaerobic properties, appears to have a useful role in therapy when applied topically to a pressure ulcer. Commercially available products include 0.75% and 1% creams, gels, lotions, and intravenous solutions. Of the 59 cases viewed throughout several publications, 56 reported nearly complete odor resolution in two to seven days when metronidazole was applied to the wound two or three times daily. Virtually no systemic adverse events have been reported in the literature, despite the risk for systemic absorption. A need remains to monitor for toxicities such as nausea, gastrointestinal distress, and neural toxicities from long-term use.

Student and faculty perceptions of lecture recording in a doctor of pharmacy curriculum.

OBJECTIVE: To describe students' and faculty members' perceptions of the impact of lecture recording in a doctor of pharmacy (PharmD) curriculum. METHODS: Second- and third-year pharmacy students and faculty members completed an anonymous survey instrument regarding their perceptions of lecture recording with 2 classroom lecture capture software programs, Camtasia Studio and Wimba Classroom. RESULTS: Most students (82%) responded that Camtasia was very helpful and almost half (49%) responded that Wimba Classroom was helpful (p<0.001). Forty-six percent of the students reported being more likely to miss a class that was recorded; however, few students (10%) reported using recordings as a substitute for attending class. The most common concern of faculty members was decreased student attendance (27%). CONCLUSION: Pharmacy students consider lecture recordings beneficial, and they use the recordings primarily to review the lecture. While faculty members reported concerns with decreased attendance, few students reported using recordings as an alternative to class attendance.

Medication discrepancies identified at time of hospital discharge in a geriatric population.

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.

The potential role of ketamine in hospice analgesia: a literature review.

OBJECTIVE: The objective of this review is to examine the role of ketamine as an analgesic for palliative treatment in the hospice care setting. DATA SOURCES: The sources referenced in this review were found September 22, 2005, via an Internet search of the MEDLINE database and Cochrane Database of Systematic Reviews. Search terms included analgesia, cancer pain, dextromethorphan, hospice, ketamine, opioids, palliative care, neuropathic pain, and morphine. Articles and case reports were included that relate to ketamine use as an analgesic agent and not as an anesthetic. DATA EXTRACTION: Because of patient variability with ketamine use and dosing, focus was placed on analgesic benefit versus no analgesic benefit. Because of the lack of controlled trials, application of all analgesic data related to ketamine use was relevant to this review. The strength of evidence is currently moderate, but the available trials and reports reviewed in this paper describe compelling results. DATA SYNTHESIS: Ketamine has been effective in producing analgesia in patients receiving palliative care, especially when used in combination with opioids. CONCLUSION: When opioid therapy is no longer sufficient to improve quality of life in the hospice setting, the addition of ketamine may be considered as adjunctive therapy.

Use of the cognitive performance scale to identify under- and over-treatment of cognitive deficits in nursing home residents with dementia.

OBJECTIVE: To determine the practicality of using the Minimum Data Set (MDS) Cognitive Performance Scale (CPS) to evaluate the appropriateness of acetylcholinesterase inhibitor (AChEI) use in the treatment of Alzheimer's disease and related disorders. DESIGN: A cross-sectional study of nursing facility residents using the medical record and MDS data. SETTING: Three skilled nursing facilities. PATIENTS/PARTICIPANTS: 275 residents with MDS assessments completed from March 1 through September 30, 2000. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): CPS scores and documented diagnoses for those residents who received and did not receive AChEI therapy. RESULTS: The median CPS score for all subjects was 3 (range, 0-6), with significant differences (P = .000; chi square) among the facilities. Overall, 13.8% of subjects received an AChEI, most commonly donepezil. As only 12.9% of residents with mild to moderate impairment were receiving an AChEI, they may have been under-treated. However, over-treatment may have been an issue among the 16.2% of subjects with severe impairment who were treated. Differences among facilities could have reflected differences in patient populations or procedures used to complete the MDS. CONCLUSION: The CPS is a practical tool for nursing facilities to use to standardize the assessment of cognitive function. The CPS could be used by pharmacists and others as an adjunct to the assessment of the effectiveness of interventions, such as AChEI therapy, to improve or maintain the functional status of nursing facility residents. Further studies are necessary before the CPS could be used, by itself, to direct pharmacotherapy of cognitive impairment.

Grapefruit juice and potential drug interactions.

OBJECTIVE: To review current literature pertaining to the potential interaction of several classes of drugs with grapefruit juice, and to discuss the mechanism and causative agents in such interactions. DATA SOURCES: A MEDLINE search covering the period 1989-2002 was performed to identify review articles, studies, and case reports referencing the potential interaction of grapefruit juice with several classes of drugs. The bibliographies of the selected articles were reviewed for additional references. STUDY SELECTION: Human studies and case reports describing the mechanism and potential interaction of grapefruit juice and several classes of drugs. DATA EXTRACTION: Studies were reviewed for design characteristics, as well as data relevant to the severity of a drug or drug class' interaction with grapefruit juice. Data were also extracted relevant to the possible causative agents of an interaction with grapefruit juice. DATA SYNTHESIS: Grapefruit juice acts by blocking the activity of cytochrome P-450 (CYP) 3A4 isoenzyme in the intestinal wall, thereby preventing the presystemic first-pass metabolism of a wide range of drugs. Studies and case reports continue to analyze the specific active components of grapefruit juice and the medications with which it interacts. CONCLUSION: Researchers continue to work to determine the constituents of grapefruit juice responsible for CYP enzyme inhibition and P-glycoprotein activation in clinical settings. Some trials have pointed researchers in the direction of compounds such as naringin, naringenin, and 6,7-dihydroxybergamottin as possible active agents. Calcium channel antagonists, neuropsychiatric medications, statins, and antihistamines are just a few of the drug classes whose actions are significantly affected by the consumption of grapefruit juice. Patients and other health care professionals need to be educated about potential drug interactions with grapefruit juice.