Diabetic patient compliance as a function of counseling. 1979.

The impact of a specially designed patient education program upon the diabetes-related knowledge and compliance of insulin dependent diabetic patients was investigated. The program consisted of an audiovisual presentation, illustrated handout material, and pharmacist-patient counseling. Based on statistical considerations, 65 eligible patients were assigned systematically to a control group (Group I) and a study group (Group II) and were evaluated for compliance following a standardized protocol. Immediately following the interview, Group II patients were instructed utilizing the patient education program. Scores for initial and final evaluations of knowledge and compliance were compared using appropriate statistical procedures. The program was successful in producing improvements in both knowledge and compliance but a need for individualization of patient education efforts was indicated. Significant improvements in compliance were not observed among patients older than the mean age for study patients and those with diabetes complicated by cardiovascular and hypertensive disease.

Avoiding polypharmacy and iatrogenesis in the nursing home.

The vast majority of nursing home patients over age 65 take at least one prescription medicine, and, on average, seven drugs are concurrently prescribed for each of these patients. One result of this polypharmacy is an increased risk of iatrogenic disease. The authors discuss traditional prescribing patterns in nursing homes and how these patterns contribute to drug-drug and drug-disease interactions in nursing home patients, as well as strategies to reduce polypharmacy and iatrogenesis.

Institutionalisation and drug use in older adults in the US.

Since the introduction of Medicaid and Medicare in the US in 1965, the rate of use of nursing homes by elderly persons has more than doubled. Nursing home care accounts for about 8% of the healthcare budget. The rate of nursing home use by elderly people and the subsequent costs are expected to increase during the 1990s. The elderly nursing home population have a disproportionately high rate of drug consumption; it has been estimated that up to one-third of elderly nursing home residents receive 8 to 12 drugs per day. Multiple drug use is a risk factor for morbidity in elderly patients. Recent regulations have tried to rationalise the use of particular classes of drugs in nursing homes, with some success. However, multiple drug use is not necessarily unjustified, given the complex comorbidity seen in some patients. Since the value of many drugs has not been proven in the elderly population, further studies are required to prove the value of drugs used in this patient population in improving function and quality of life. Regular review of total regimens should be undertaken often.

Drug prescribing for the elderly.

Both the geriatric population of the United States and the use of prescription drugs by this age group continue to increase. Cardiovascular medicines, analgesics, anti-inflammatories, and psychotropic medications are used most commonly. Polypharmacy, defined as a condition in which a patient receives too many drugs, drugs for too long, or drugs in exceedingly high doses, often results.

Physiological changes due to age. Pharmacodynamic changes of drug action and implications for therapy.

The elderly respond differently to drugs than do younger people. Their physiological response is much more variable, and predictability of drug action is much less certain. When all non-pharmacological factors and age-associated pharmacokinetics are taken into account, there is still no full explanation of the potentially altered drug action and increased drug toxicity observed in the elderly. It is only relatively recently that age-associated physiological changes (primary age changes), their interplay with age-associated pathophysiological changes (secondary age changes) and environmental changes (tertiary age changes) have been studied with regard to the effect of those changes on the pharmacodynamics of drug action. In general, age-associated pharmacodynamic changes, i.e. changes in the type, intensity and duration of drug action, have been associated with changes in receptor function (e.g. altered receptor number and affinity, altered second messenger function, altered cell response), changes in the homeostatic mechanisms, and reduced reserve capacity. It is important to realise that these changes, which can differ greatly among patients, may be responsible for an increased incidence of adverse drug reactions and therapeutic failure. They may also mandate a higher dose in some circumstances, as some organs become less responsive to drug action with age.

Adverse drug effects.

Adverse drug effects afflict the elderly with greater frequency than the young. Several factors are responsible, among them the age-related alterations in pharmacokinetics and pharmacodynamics. Most importantly, it is the number of drugs taken on a daily basis that is cited as being the cause. When one extends the concept of adverse drug reactions to the concept of adverse drug events, then errors made by the patient, caregiver, and/or health care provider appear to be responsible to a large degree.

Comparing fact sheets and lectures to provide investigational drug information.

This article describes a study to evaluate the effectiveness of two methods (fact sheets and lectures) of providing investigational drug information.

Nonprescription drugs and the elderly.

The trend toward self-care is increasing among elderly patients. Over-the-counter medications contribute to the well-being of older patients, but adverse effects may occur, including interactions with prescription drugs. Nondrug health care products and agents for external use are also helpful when properly used. Dry skin, dry eyes, arthritis, pain and gastrointestinal complaints are among the major indications for the use of nonprescription medications.

Pharmacotherapeutics in the elderly.

Drugs are the most cost-effective modality of chronic care, and older adults with multiple illnesses often need multiple drugs. Because this may lead to drug interactions, adverse drug effects, and problems with compliance, drug regimens should be individualized and as few drugs as possible used. When a new drug is indicated, it is important for the physician reassess the appropriateness and continued need for the existing regimen. Patients and providers must agree on a particular regimen, its goals, promises, and limitations.

Potential adverse effects of antihypertensive drugs in the elderly.

Antihypertensive therapy is effective in elderly patients, at least in those under 80 years old. Stepped care may still serve as a therapeutic framework which is modified to fit the individual elderly patient, according to the risk: benefit ratio. However, there are no risk-free drugs and no antihypertensive agent is universally effective. The elderly are probably more sensitive than younger patients to the adverse effects of antihypertensive drugs, for various reasons, among which are age- and disease-related changes that can lead to altered pharmacodynamics and pharmacokinetics. Multiple pathology and multiple drug therapy is likely to lead to an increased number of drug-drug and drug-disease interactions in the elderly. The elderly are probably most at risk from side effects that influence the cardiovascular and the central nervous system.

Antihypertensive therapy for the elderly: an expert system to assist therapeutic decisions.

The prevalence of hypertension among the elderly is high. Recent multicenter studies have shown hypertension, especially isolated systolic hypertension, to be a risk factor and treatment to be effective, if individualized. In addition, the presence of multiple complicating conditions and the need for multiple medications in the elderly increases the required medical knowledge base necessary to appropriately determine antihypertensive therapy. To assist the primary provider, an expert system has been developed that provides advice on therapeutic decisions for elderly patients (greater than 65 years old and less than 85 years old). It takes into account such factors as age, sex, lifestyle, site of care, nutritional status, physiologic and pathophysiologic changes, co-existing diseases, multiple drug use, and prior antihypertensive drug exposure and response. The system user enters patient characteristics, disease states, risk factors, relevant laboratory values, and prior drug therapy. The system responds with a set of recommendations of appropriate therapy individualized for the specific patient. To further assist the process, relative costs of therapy are also included. The system, consisting of over 200 rules, is currently undergoing validation by a panel of cardiologists. It is implemented in IBM's Expert System Environment (ESE) on the IBM 4341. The authors wish to acknowledge the contribution of the ESE software by the IBM Corporation.

Medication management.

The elderly receive more drugs than any other patient group, and those in nursing homes receive the most. However, little is known about drug action, particularly in the very old. A host of factors can alter drug action. Particular attention needs to be paid to the influence of intercurrent disease, other drugs in a particular regimen, the patient's weight and nutritional status, as well as altered pharmacokinetic and pharmacodynamic characteristics of any drug. Liver and kidney status, and changes therein, are most important.

Age-associated pharmacodynamic changes.

Many pharmacodynamic changes with age have been identified. Quite likely, they, in concert with age-associated pharmacokinetic changes and multiple drug use, are responsible for altered drug action in the elderly and an increasing incidence of adverse drug reactions with age. The pharmacodynamic changes, which can result in altered action of important drugs, can lead to major adverse clinical outcomes if not recognized, particularly in those drugs which affect the heart and the central nervous system.