Adverse drug events in hospitalized elderly.

BACKGROUND: The study objectives were (a) to describe the occurrence, types, and preventability of adverse drug events (ADEs) in hospitalized patients 70 years of age and older; (b) to examine the association between potential risk factors and ADEs; and (c) to examine the relationship of an ADE occurrence and hospital length of stay (LOS) and functional decline. METHOD: Consecutive general medical admissions (n = 157) of community-dwelling persons were prospectively monitored daily for ADE occurrence. Admission assessment included demographic factors, cognition, preadmission medication use, and functional status. Discharge assessment included functional status. LOS, discharge diagnoses, and medication use during the hospitalization. RESULTS: Twenty-three patients (14.6%) experienced 28 probable ADEs, of which 54.2% (13/24) were judged to be potentially preventable. Patients experiencing an ADE had a significantly lower mean Mini-Mental State Examination score (23.6 +/- 4.3 vs 25.5 +/- 3.6, p = .039) and were prescribed significantly more new inpatient medications (4.0 +/- 2.3 vs 2.6 +/- 1.7, p = .01) compared to non-ADE patients. Age, gender, functional status prior to admission, percent with more than four active diagnoses, or number of preadmission medications were not associated with ADE status. Upon discharge, 50.0% of ADE patients experienced a decline in one or more activities of daily living (ADLs), compared with 24.1% of non-ADE patients (p = .017). ADE patients had a longer LOS (8.7 +/- 4.9 vs 6.6 +/- 3.0 days, p = .022) compared to non-ADE patients. CONCLUSIONS: ADEs were associated with number of new inpatient medications and admission cognitive status, but not demographic, disease, or physical function variables. Patients experiencing an ADE were more likely to experience a longer LOS and to decline in ADL function. ADEs may be one factor contributing to functional decline during hospitalization. Future research in this area should include larger samples and multivariable analyses controlling for potential confounders.

Depression, cognitive impairment, and understanding of medication directions in hospitalized elderly patients.

PURPOSE: The objectives of this study were 1) to assess understanding of medication directions of drug therapy in a group of hospitalized elderly who were not receiving assistance with medication administration; and 2) to determine whether depression, cognitive impairment, age, and other characteristics are associated with patient understanding of medication directions. METHODS: The sample consisted of 117 hospitalized elderly patients aged 70 years and older who were taking two or more medications prior to hospitalization and reported medication self-administration. Data collection included demographic characteristics, mood, cognition, and pre-admission medication use and knowledge. RESULTS: Thirteen (11%) patients did not understand directions for two or more pre-admission medications. Being 80 years or older was associated with not understanding medication directions (OR = 6.2, p = .017). There was a trend for depressive symptoms to be associated with not understanding medication directions, however, this was not significant (OR = 3.9, p = .058). CONCLUSIONS: Although all individuals should be assessed for comprehension of their medication regimens, those over 80 years of age with depressive symptoms deserve increased attention. Alternative strategies may need to be developed to improve medication knowledge in the older, depressed hospitalized patient.

Polymyalgia rheumatica.

The epidemiology, relationship to giant cell arteritis (GCA), pathogenesis, pathology, clinical and laboratory features, differential diagnosis, and treatment of polymyalgia rheumatica (PMR) are reviewed. Patients with PMR are usually over 50 years of age, white, and female. There is an association between GCA and PMR that has important implications because of the risk of blindness and other severe vascular complications in patients with GCA. The causes of PMR and GCA are unknown, although the immune system is implicated in the pathogenesis of these diseases. PMR is characterized by muscle pain and stiffness in the shoulders and hips. The principal laboratory finding is an elevated erythrocyte sedimentation rate. The differential diagnosis of PMR includes a number of diseases that cause symmetrical arthritis. It may be particularly difficult to distinguish between PMR and GCA because patients with GCA usually have symptoms associated with PMR. Nonsteroidal anti-inflammatory agents may be effective in mild cases of PMR. However, corticosteroids, usually prednisone or prednisolone, are the class of drugs most widely used to treat PMR. They are effective in relieving the pain and reversing the abnormal laboratory values in most patients; responses can be apparent in 24-48 hours. Steroid-sparing agents such as methotrexate, dapsone, and azathioprine have no established role at present. Patients taking corticosteroids for PMR should be monitored for the occurrence of GCA and development of adverse effects associated with drug therapy. Corticosteroids are effective in treating PMR. Although patients with PMR must be monitored for the development of GCA, the prognosis for these patients is excellent.

Hepatic and renal dysfunction following nafcillin administration.

OBJECTIVE: To review four cases of combined hepatic and renal toxicity that may be associated with the administration of nafcillin in adults. This type of adverse event with the use of nafcillin has not been previously documented in the literature. DATA SOURCES: References from pertinent articles are identified throughout the text. DATA SYNTHESIS: Nafcillin is a widely used penicillinase-resistant penicillin. In four patients receiving nafcillin doses greater than 9 g/24 hours, changes in renal and hepatic function markers were noted within 72 hours of the initiation of nafcillin therapy. Laboratory values returned toward baseline when nafcillin therapy was discontinued. Elevations in blood urea nitrogen, creatinine, total bilirubin, and lactate dehydrogenase have been previously described in the literature for penicillin-like agents other than nafcillin. The exact mechanism for such toxicities as well as patient risk factors have not been clearly established. CONCLUSIONS: Caution should be taken when initiating nafcillin therapy. Evaluation of renal and liver function tests prior to initiating nafcillin therapy and within the first 72 hours appears warranted. If hepatic and/or renal toxicity is observed, discontinuation of nafcillin should be considered.

Risk of nephrotoxicity with combination vancomycin-aminoglycoside antibiotic therapy.

One hundred five patients receiving concurrent aminoglycoside and vancomycin therapy of at least 5 days' duration were retrospectively reviewed for development of nephrotoxicity. All had their vancomycin and aminoglycoside serum concentrations controlled by a clinical pharmacokinetics service. Nephrotoxicity occurred in 28 (27%) of the patients. Twenty-two of the 28 had other factors that are known to contribute to renal failure (amphotericin B therapy, sepsis, liver disease, obstructive uropathy, pancreatitis, anesthesia). The remaining six developed nephrotoxicity without other known contributing factors. Logistic regression analysis revealed associations between nephrotoxicity and age, sex, aminoglycoside trough and vancomycin peak and trough serum concentrations, length of aminoglycoside and vancomycin therapy, concurrent amphotericin B therapy, liver disease, neutropenia, and peritonitis (p less than 0.05). In addition to factors previously reported, this study found that neutropenia and peritonitis are associated with an increased risk of nephrotoxicity. Patients with one or more risk factors warrant close monitoring of renal function as well as vancomycin and aminoglycoside serum concentrations.