Potential drug-drug and drug-disease interactions in well-functioning community-dwelling older adults.

WHAT IS KNOWN AND OBJECTIVE: There are few studies examining both drug-drug and drug-disease interactions in older adults. Therefore, the objective of this study was to describe the prevalence of potential drug-drug and drug-disease interactions and associated factors in community-dwelling older adults. METHODS: This cross-sectional study included 3055 adults aged 70-79 without mobility limitations at their baseline visit in the Health Aging and Body Composition Study conducted in the communities of Pittsburgh PA and Memphis TN, USA. The outcome factors were potential drug-drug and drug-disease interactions as per the application of explicit criteria drawn from a number of sources to self-reported prescription and non-prescription medication use. RESULTS: Over one-third of participants had at least one type of interaction. Approximately one quarter (25·1%) had evidence of had one or more drug-drug interactions. Nearly 10·7% of the participants had a drug-drug interaction that involved a non-prescription medication. % The most common drug-drug interaction was non-steroidal anti-inflammatory drugs (NSAIDs) affecting antihypertensives. Additionally, 16·0% had a potential drug-disease interaction with 3·7% participants having one involving non-prescription medications. The most common drug-disease interaction was aspirin/NSAID use in those with history of peptic ulcer disease without gastroprotection. Over one-third (34·0%) had at least one type of drug interaction. Each prescription medication increased the odds of having at least one type of drug interaction by 35-40% [drug-drug interaction adjusted odds ratio (AOR) = 1·35, 95% confidence interval (CI) = 1·27-1·42; drug-disease interaction AOR = 1·30; CI = 1·21-1·40; and both AOR = 1·45; CI = 1·34-1·57]. A prior hospitalization increased the odds of having at least one type of drug interaction by 49-84% compared with those not hospitalized (drug-drug interaction AOR = 1·49, 95% CI = 1·11-2·01; drug-disease interaction AOR = 1·69, CI = 1·15-2·49; and both AOR = 1·84, CI = 1·20-2·84). WHAT IS NEW AND CONCLUSION: Drug interactions are common among community-dwelling older adults and are associated with the number of medications and hospitalization in the previous year. Longitudinal studies are needed to evaluate the impact of drug interactions on health-related outcomes.

Patient safety culture assessment in the nursing home.

OBJECTIVE: To assess patient safety culture (PSC) in the nursing home setting, to determine whether nursing home professionals differ in their PSC ratings, and to compare PSC scores of nursing homes with those of hospitals. METHODS: The Hospital Survey on Patient Safety Culture was modified for use in nursing homes (PSC-NH) and distributed to 151 professionals in four non-profit nursing homes. Mean scores on each PSC-NH dimension were compared across professions (doctors, pharmacists, advanced practitioners and nurses) and with published benchmark scores from 21 hospitals. RESULTS: Response rates were 68.9% overall and 52-100% for different professions. Most respondents (76%) were women and had worked in nursing homes for an average of 9.8 years, and at their current facility for 5.4 years. Professions agreed on 11 of 12 dimensions of the survey and differed significantly (p<0.05) only in ratings for one PSC dimension (attitudes about staffing issues), where nurses and pharmacists believed that they had enough employees to handle the workload. Nursing homes scored significantly lower (ie, worse) than hospitals (p<0.05) in five PSC dimensions (non-punitive response to error, teamwork within units, communication openness, feedback and communication about error, and organisational learning). CONCLUSIONS: Professionals in nursing homes generally agree about safety characteristics of their facilities, and the PSC in nursing homes is significantly lower than that in hospitals. PSC assessment may be helpful in fostering comparisons across nursing home settings and professions, and identifying targets for interventions to improve patient safety.

Pharmacological and clinical aspects of antiepileptic drug use in the elderly.

In this article, epidemiological and clinical aspects related to the use of antiepileptic drugs (AEDs) in the elderly are highlighted. Studies have shown that people with epilepsy receiving AED treatment show important deficits in physical and social functioning compared with age-matched people without epilepsy. To what extent these deficits can be ascribed to epilepsy per se or to the consequences of AED treatment remains to be clarified. The importance of characterizing the effects of AEDs in an elderly population is highlighted by epidemiological surveys indicating that the prevalence of AED use is increased in elderly people, particularly in those living in nursing homes. Both the pharmacokinetics and the pharmacodynamics of AEDs may be altered in old age, which may contribute to the observation that AEDs are among the drug classes most commonly implicated as causing adverse drug reactions in an aged population. Age alone is one of several contributors to alterations in AED response in the elderly; other factors include physical frailty, co-morbidities, dietary influences, and drug interactions. Individualization of dosage, avoidance of unnecessary polypharmacy, and careful observation of clinical response are essential for an effective and safe utilization of AEDs in an elderly population.

Epidemiology of over-the-counter drug use in community dwelling elderly: United States perspective.

Among US community dwelling individuals aged > or = 65 years, about as many persons take nonprescription drugs as take prescription drugs. A review of US data from the last 2 decades indicates that the average number of over-the-counter (OTC) drugs taken daily is around 1.8, but varies with geographical area (highest in the Midwest) and race/ethnicity (lowest use among Hispanics, followed by African Americans. and highest use among Whites). Use has consistently been found to be higher in women than in men. While OTC use appears to be increasing over time, it also decreases with increase in age. The most common OTC classes used are analgesics, laxatives and nutritional supplements. Our ability to explain or to predict OTC use and change in use is poor, and further studies, particularly on use by elderly individuals of minority races, are needed.

Pain in nursing home residents: management strategies.

Pain is prevalent and undertreated in nursing home residents, despite the existing wide array of effective pharmacological and nonpharmacological treatment modalities. In order to improve the quality of life of these vulnerable individuals, practitioners require education about the correct approach to assessment and management. Assessment should be comprehensive, taking into account the basic underlying pathology (e.g. osteoarthritis, osteoporosis, peripheral neuropathy, fibromyalgia, cancer) as well as other contributory pathology (e.g. muscle spasm, myofascial pain) and modifying comorbidities (e.g. depression, anxiety, fear, sleep disturbance). Pharmacological management should be guided by a stepped-care approach, modelled after that recommended by the World Health Organization for treatment of cancer pain. Nonopioid and opioid analgesics are the cornerstone of pharmacological pain management. Tricyclic antidepressants and anticonvulsants can be very effective for the treatment of certain types of neuropathic pain. In addition to treating the pain per se, attention should be given to prevention of disease progression and exacerbation, as maintaining function is of prime importance. Nursing home residents with severe dementia challenge the practitioner's pain assessment skills; an empirical approach to treatment may sometimes be warranted. The success of treatment should be measured by improvement in pain intensity as well as physical, psychosocial and cognitive function. Effective pain management may impact any or all of these functional domains and, therefore, substantially improve the nursing home resident's quality of life.

Suboptimal prescribing in older inpatients and outpatients.

Investigators searched Medline and HealthSTAR databases from January 1, 1985 through June 30, 1999 to identify articles on suboptimal prescribing in those age 65 years and older. 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. The definitions for various types of suboptimal prescribing (polypharmacy, inappropriate, and underutilization) are numerous, and measurement varies from study to study. The literature suggests that suboptimal prescribing is common in older outpatients and inpatients. Moreover, there is significant morbidity and mortality associated with suboptimal prescribing for these older patients. Evidence from well-controlled studies suggests that multidisciplinary teams and clinical pharmacy interventions can modify suboptimal drug use in older people. Future research is necessary to measure and test other methods for tackling this major public health problem facing older people.

Impact of estrogen use on decline in cognitive function in a representative sample of older community-resident women.

The authors investigated whether postmenopausal estrogen use helps to maintain cognitive function; a brief screen, the Short Portable Mental Status Questionnaire (SPMSQ), was used. Information was gathered from a stratified, random sample of 1,907 African-American and White women (aged 65-100 years) participating in the longitudinal Duke Established Populations for Epidemiologic Studies of the Elderly project carried out in five urban and rural counties of North Carolina. All women were cognitively unimpaired in 1986-1987 and were evaluated 3 and 6 years later. Decline in cognitive function was measured as an increase of two or more errors on the SPMSQ and crossing of an SPMSQ threshold indicative of cognitive impairment. Recency and continuity of estrogen use were measured. Univariate analyses indicated that recent (crude odds ratio = 0.42, 95% confidence interval: 0.21, 0.86) and continuous (crude odds ratio = 0.32, 95% confidence interval: 0.13, 0.81) estrogen use reduced the risk of cognitive decline but not of cognitive impairment. After adjustment for demographic and health characteristics, protective effects became nonsignificant. While postmenopausal use of estrogen may be protective for Alzheimer's disease, current findings based on a brief cognitive screen suggest that it is not protective for cognitive decline related to aging.

Sedative, hypnotic, and antianxiety medication use in an aging cohort over ten years: a racial comparison.

OBJECTIVES: Prescriptions of sedatives, hypnotics, and antianxiety medications have decreased over the past 15 years. However, racial differences have not been well investigated in controlled analyses. DESIGN: A prospective cohort study. SETTINGS AND PARTICIPANTS: The authors analyzed data from a community-based, biracial cohort of older adults (n = 4,000 at baseline) followed for 10 years to determine sociodemographic and health characteristics associated with the use of these medications between 1986 and 1996. MAIN OUTCOME MEASURES: Information about sedative, hypnotic, and antianxiety medication use and demographic and health characteristics was obtained from a race-stratified, probability-based sample of black and white community-dwelling older adults in the Piedmont region of North Carolina during four in-person interviews spanning 10 years. Descriptive statistics were calculated. Logistic regression was used for the final models. RESULTS: A total of 13.3% of the subjects were taking these medications in 1986, with the frequency of use declining only to 11.8% in 1996 despite the cohort aging 10 years. Correlates of use at baseline were female gender, white race, depressive symptoms, poor self-rated health, impaired physical function, and health services use. These correlates persisted for each of the three follow-up waves of the survey. In 1996, the odds for being white and using these medications was 4.70 in controlled analyses. CONCLUSIONS: Despite the overall decline in the use of sedative, hypnotics, and antianxiety agents in the general population in recent years, over the 10 years of this survey, an aging cohort continued to use these medications at a frequency greater than the general population and did not demonstrate a significant decline in use. Factors unrelated to health status, specifically being white, were among the strongest correlates of use throughout the years of follow-up.

Recent advances in geriatrics: drug-related problems in the elderly.

OBJECTIVE: To review recent articles examining drug-related problems in the elderly and comment on their potential impact on geriatric pharmacy practice. DATA SOURCES: Six articles published in 1997 and 1998. DATA SYNTHESIS: One study estimated that the cost of drug-related morbidity and mortality with the services of consultant pharmacists was $4 billion, compared with $7.6 billion without the services of consultant pharmacists. A study of ambulatory elderly patients with polypharmacy documented that 35% reported experiencing at least one adverse drug event within the previous year. Another study of ambulatory elderly found that in those with discontinued medications, adverse drug withdrawal events were uncommon. Two studies, one from Canada and one from the US, describe the development, by consensus, of explicit criteria for defining and identifying inappropriate drug use in the elderly (i.e., drugs to avoid, drugs with dose limits, drug-drug and drug-disease interactions). Finally, a modified Delphi survey of an expert panel reached consensus on 18 potential risk factors for drug-related factors in long-term care facility residents. CONCLUSIONS: Drug-related problems are considerable for elderly patients. Data from published studies should provide some guidance for today's practitioners as well as direction regarding future research.

Marked differences in antidepressant use by race in an elderly community sample: 1986-1996.

OBJECTIVE: Prescriptions of antidepressant medications have increased significantly over the past 15 years across the life cycle. One overall correlate of medication use in older adults is race, with African Americans using fewer medications than whites. Given the frequency of depressive symptoms among elderly populations, as well as the increased potential for adverse side effects from antidepressants, the relative contribution of race in the use of antidepressants is critical for determining well-designed studies. The authors analyzed data from a community-based cohort of elders followed for 10 years to determine the association of race to the use of antidepressants between 1986 and 1996, with control for known correlates of depression in late life. METHOD: Information on antidepressant use and demographic and health characteristics were obtained from a stratified, probability-based sample of 4,162 elders (equally distributed between African American and white community-dwelling subjects) in the Piedmont region of North Carolina during four in-person interviews spanning 10 years. Descriptive statistics were calculated. Logistic regression was used for the final models. RESULTS: A total of 4.6% of whites and 2.3% of African Americans used antidepressants in 1986. Approximately 14.3% of whites and 5.0% of African Americans used antidepressants in 1996. In controlled analyses, the prevalence odds ratio for antidepressant use in whites, compared to African Americans, was 1. 76 in 1986 and 3.77 in 1996. CONCLUSIONS: African American elders are much less likely to take antidepressants, and the difference in use increased over the 10 years of the survey.

Inappropriate drug use among community-dwelling elderly.

This study examined inappropriate drug use defined by updated criteria among respondents in the second and third in-person waves of the Duke Established Populations for Epidemiologic Studies of the Elderly. Information about sociodemographics, health status, access to health care, and drug use was determined by in-home interviews. Drug use was coded for therapeutic class and appropriateness by applying explicit criteria. Among participants, 27% of the second and 22.5% of the third in-person wave took one or more inappropriate agents. Of these drugs, the most common therapeutic classes were central nervous system and cardiovascular. Longitudinal multivariate analyses found that persons taking several prescription drugs, those having continuity of care, those who previously took inappropriate drugs, and those with many health visits were most likely (p<0.05) to use inappropriate drugs. We conclude that inappropriate drug use is common among community-dwelling elderly.

Calcium channel blockers and cancer.

PURPOSE: We sought to explore the relation that has been previously reported between calcium channel blockers and an increased risk of cancer. SUBJECTS AND METHODS: We followed 3,511 participants, age 65 years or older, in the Duke Established Populations for Epidemiologic Studies of the Elderly for up to 10 years. Information about use of medications was obtained at baseline and 3 and 6 years later. Information about hospitalization for cancer, or death from cancer, was obtained from Health Care Financing Administration data and death certificates. RESULTS: Of the 133 users of calcium channel blockers, 16 (12%) developed cancer, compared with 548 (16%) of 3,378 nonusers (hazard ratio = 0.9; 95% confidence interval, 0.5 to 1.5). Adjusting for baseline and time-dependent covariates, such as race, diabetes, or blood pressure, for dose or class of calcium channel blockers, or for length of follow-up, had no effect. CONCLUSIONS: Use of calcium channel blockers does not appear to be related to cancer risk. Earlier reports showing such a relation may have been the result of chance.

Substernal epicardial echocardiography: a new ultrasonic window to the postoperative heart.

Echocardiographic examination of the postoperative cardiac surgery patient is often problematic because of a poor acoustic window that requires imaging by transesophageal echocardiography. Furthermore, no available echocardiographic methods exist for simple ongoing beat-to-beat assessment of postoperative left ventricular size and function. We designed a modification of a mediastinal drain to allow a transesophageal echocardiography probe to be placed adjacent to the epicardial surface of the heart. After chest closure in a series of 13 patients, we were able to obtain 5- and 7-MHz epicardial images of high quality in both short- and long-axis planes, which also allowed Doppler examination of aortic, mitral, and tricuspid valves in 10 patients. This technique was suitable for prolonged and serial assessment of left ventricular size and function. Though preliminary, these observations suggest that this new substernal epicardial echocardiographic window to the postoperative heart offers a potential for prolonged monitoring of cardiac function as well as rapid and accurate diagnosis in problematic patients.

Association of race and other potential risk factors with nonvertebral fractures in community-dwelling elderly women.

This study determined potential associations of sociodemographic, lifestyle, health, and drug use factors known to affect bone metabolism with incident nonvertebral fractures. The baseline sample consisted of 2,590 female, nonproxy subjects from the Duke Established Populations for Epidemiologic Studies of the Elderly, which focuses on five adjacent counties in the Piedmont area of North Carolina. Information about potential risk factors was collected during a baseline in-home interview during 1986-1987. Subsequent nonvertebral fractures were reported at follow-up interviews during the annual follow-up periods (1988-1993). The authors used multivariate analyses in which weighted data were adjusted for sampling design. After controlling for other potential confounding sociodemographic, lifestyle, health, and drug use factors, they found that African American race (adjusted odds ratio (OR) = 0.43, 95% confidence interval (CI) 0.31-0.58), age (adjusted OR = 1.04, 95% CI 1.01-1.06), alcohol consumption (adjusted OR = 1.61, 95% CI 1.01-2.57), being underweight (adjusted OR = 1.63, 95% CI 1.13-2.34), cognitive impairment (adjusted OR = 1.67, 95% CI 1.12-2.48), impaired mobility (adjusted OR = 1.15, 95% CI 1.03-1.29), and phenytoin use (adjusted OR = 2.93, 95% CI 1.04-8.30) were associated with first fracture occurrence. Similar findings were observed for nonhip, nonvertebral fractures. African Americans were less likely than Whites to have nonvertebral fractures, and these differences were not related to lifestyle or health factors examined in this study.

Effects of central nervous system polypharmacy on falls liability in community-dwelling elderly.

BACKGROUND: While central nervous system (CNS) active medications such as psychotropics and narcotic analgesics have been implicated in contributing to falls in older adults, the combined effect of multiple CNS-active medications has not been investigated. The purpose of this study was to examine the influence, in community-dwelling elderly, of (1) taking multiple CNS-active medications on fall liability and (2) individual classes of CNS-active medications (using discrete drug classification) on the risk of falls after controlling for important confounders--age, mobility, cognition and depression. METHODS: 305 community-dwelling male veterans (age: 70-104) were screened at study entry for mobility, cognition and depression. CNS-active medications were categorized as benzodiazepines, other sedative-hypnotics, neuroleptics, tricyclic antidepressants, and opioid analgesics. Subjects were prospectively followed for 6 months to monitor falls; at the end of this time period, subjects were classified as fallers (at least one fall) or nonfallers. The relationship between CNS-active drug use and falls was examined using multivariable analyses. RESULTS: The risk of falls was significantly greater in CNS-active medication users as compared with nonusers. Adjusted odds ratio for one CNS-active drug was 1.54 (95% confidence interval 1.07-2.22) and for two or more agents 2.37 (95% confidence interval 1.14-4.94). CONCLUSIONS: In community-dwelling elderly, the use of multiple CNS-active medications is associated with enhanced falls liability, over and above the use of one CNS-active drug alone. This apparent dose-response relationship provides support for causality.

The cost-effectiveness of a clinical pharmacist intervention among elderly outpatients.

We estimated the cost and cost-effectiveness of a clinical pharmacist intervention known to improve the appropriateness of drug prescribing. Elderly veteran outpatients prescribed at least five drugs were randomized to an intervention (105 patients) or control (103) group and followed for 1 year. The intervention pharmacist provided advice to patients and their physicians during all general medicine visits. Mean fixed and variable costs/intervention patient were $36 and $84, respectively Health services use and costs were comparable between groups. Intervention costs ranged from $7.50-30/patient/unit change in drug appropriateness. The cost to improve the appropriateness of drug prescribing is thus relatively low.

Medication use patterns among demented, cognitively impaired and cognitively intact community-dwelling elderly people.

OBJECTIVE: To determine whether medication use patterns in community-dwelling elderly people vary with level of cognitive function-dementia, cognitive impairment (but not dementia) and intact cognition. DESIGN: Cross-sectional survey. SETTING: A five-county area of central North Carolina, USA. PARTICIPANTS: 520 members of the Duke Established Populations for Epidemiologic Studies of the Elderly. MEASUREMENTS: Medication use in the previous 2 weeks was ascertained during a interview in the patient's home and was coded as to prescription and therapeutic class status. Cognitive status, the primary independent variable, was divided into: (i) dementia (n=100); (ii) cognitive impairment but not dementia (n=117); and (iii) cognitively intact (n=303). The dependent variables were any prescription or over-the-counter (OTC) medication use (vs non-use); number of prescription or OTC medications used; and prescription and OTC use combined within major therapeutic classes. Multivariate analyses controlled for socio-demographic characteristics, health status, functional status and access to health care. RESULTS: The use of any prescription medication was similar in the three groups. The demented were significantly less likely than cognitively impaired people to use any OTC medications (OR=0.65, 95% CI=0.45, 0.93), cardiovascular medications (OR=0.70, 95% CI=0.49, 0.99) and analgesics (OR=0.54, 95% CI=0.39, 0.75). As a combined group, those who were demented and cognitively impaired were less likely than the cognitively intact group to use any OTC medications (OR=0.78, 95% CI 0.65, 0.92). Compared with the cognitively impaired subjects, the demented group took fewer prescription medications (beta coefficient=-0.31, 95% CI=-0.59, -0.03) and similar numbers of OTC medications. Compared with those who were cognitively intact, the combined group of demented and cognitively impaired subjects took fewer OTC medications (beta coefficient=-0.14, 95% CI=-0.23, -0.05) and similar numbers of prescription medications. CONCLUSION: Increasing level of cognitive dysfunction is associated with decreased use of OTC, cardiovascular and analgesic medications and the use of fewer prescription medications. These results suggest important differences in medication use patterns among community-dwelling elderly people who vary in cognitive status.

Benzodiazepine use and cognitive function among community-dwelling elderly.

OBJECTIVE: To evaluate the relation between benzodiazepine use and cognitive function among community-dwelling elderly. METHODS: This prospective cohort study included 2765 self-reporting subjects from the Duke Established Populations for Epidemiologic Studies of the Elderly. The subjects were cognitively intact at baseline (1986-1987) and alive at follow-up data collection 3 years later. Cognitive function was assessed with the Short Portable Mental Status Questionnaire (unimpaired versus impaired and change in score) and on the basis of the number of errors on the individual domains of the Orientation-Memory-Concentration Test. Benzodiazepine use was determined during in-home interviews and classified by dose, half-life, and duration. Covariates included demographic characteristics, health status, and health behaviors. RESULTS: After control for covariates, current users of benzodiazepine made more errors on the memory test (beta coefficient, 0.35; 95% confidence interval [CI], 0.10 to 0.61) than nonusers. Further assessment of the negative effects on memory among current users suggested a dose response in which users taking the recommended or higher dose made more errors (beta coefficient, 0.57; 95% CI, 0.26 to 0.88) and a duration response in which long-term users made more errors (beta coefficient, 0.39; 95% CI, 0.05 to 0.73) than nonusers. Users of agents with long half-lives and users of agents with short half-lives both had increased memory impairment (beta coefficient, 0.32; 95% CI, 0.01 to 0.64 and beta coefficient, 0.38; 95% CI, 0.02 to 0.75, respectively) relative to nonusers. Previous benzodiazepine use was unrelated to memory problems, and current and previous benzodiazepine use was unrelated to level of cognitive functioning as measured with the other 4 tests. CONCLUSIONS: The results suggested that current benzodiazepine use, especially in recommended or higher doses, is associated with worse memory among community-dwelling elderly.