Assessing medication appropriateness in the elderly: a review of available measures.

The disproportionate use of medications, combined with age-related pharmacokinetic and pharmacodynamic changes, places older adults at high risk for medication related problems (MRPs). MRPs demonstrate significant morbidity, mortality and economic impact among healthcare systems. The negative outcomes associated with MRPs emphasise the need for more careful and thorough assessments of drug therapy among older adults. In the 1990s a number of methods and instruments were developed to assist in the assessment of medication appropriateness. These tools may be categorised by criteria as: implicit, explicit or one utilising a combination of implicit and explicit criteria. This article reviews these available tools and outlines the advantages and disadvantages of each. In conclusion, those instruments considered to be comprised of both implicit and explicit criteria offer a more thorough assessment of medication appropriateness.

Hyperventilation associated with quetiapine.

OBJECTIVE: To describe a case of hyperventilation associated with the administration of quetiapine. CASE SUMMARY: A 69-year-old African-American woman admitted to a psychiatric hospital for treatment of major depression with psychotic features was treated and successfully discharged with quetiapine, along with metronidazole and miconazole to treat bacterial/monilial vaginitis. Three days after discharge, the patient presented to a community hospital with shortness of breath and hyperventilation. The patient was admitted and treated for tachypnea and acute respiratory alkalosis. During this hospitalization, the patient was noted to have increased respiratory rate following the administration of quetiapine. DISCUSSION: Hyperventilation was reported during the clinical trials of quetiapine; however, this is the first published report to date. Serotonin is involved both centrally and peripherally in the regulation of respiration. A contributing factor in this case may have been the concomitant administration of metronidazole, which inhibits the cytochrome P450 enzyme (CYP3A4) also responsible for the metabolism of quetiapine. CONCLUSIONS: The development of hyperventilation and respiratory alkalosis was associated with the administration of quetiapine.

Vitamin E in the treatment of tardive dyskinesia.

OBJECTIVE: To review the efficacy of vitamin E in the treatment of tardive dyskinesia (TD). DATA SOURCES: Published articles and abstracts in English were identified from January 1986 to March 1999 by MEDLINE and International Pharmaceutical Abstracts searches using the terms vitamin E, alpha-tocopherol, and tardive dyskinesia. Additional articles were identified from the references of the retrieved articles and cross- referencing selected articles. DATA EXTRACTION: All clinical trials evaluating the use of vitamin E in human subjects with TD were reviewed. Selected articles also included those considered to be helpful in providing a basic introduction to TD pathophysiology and management. DATA SYNTHESIS: TD occurs in approximately 20% of patients treated with neuroleptics. The resulting dyskinesias can be irreversible and are often psychologically and physically debilitating. Recent research suggests that TD may be a result of neuronal damage inflicted by free radicals generated from increased neurotransmitter turnover and metabolism. Vitamin E as a naturally occurring free radical scavenger has been evaluated in the treatment of TD. Eighteen completed trials are available either in completed or abstract form. Twelve of these trials have produced positive results with vitamin E in the treatment of TD. Patients who have had TD for less than five years appear to respond better than patients with long-standing TD. CONCLUSIONS: Research suggests that vitamin E offers benefit in the management of a subgroup of patients with TD. Further investigation is needed to ascertain continued efficacy with long-term use as well as the role of vitamin E in TD prophylaxis.

Estrogen for dementia-related aggression in elderly men.

OBJECTIVE: To report the use of conjugated estrogens for aggression in two elderly men with dementia and to review the available literature relating to estrogen use for aggression in the elderly. CASE SUMMARIES: Case 1. A 78-year-old white man had probable Alzheimer dementia and aggression (verbal and physical) that was nonresponsive to antipsychotic, antidepressant, and mood stabilizer therapy. However, conjugated estrogens 1.875 mg/d reduced his physical aggression, as evidenced by a 75% decline in aggressive episodes, per 24-hour nursing reports and progress notes. Case 2. A 78-year-old African-American man with vascular dementia, physical aggression, and sexual inappropriateness was unsuccessfully managed with several antipsychotic and benzodiazepine trials. He did, however, exhibit a decline in physical and sexual aggression by 80%, as well as a 55% reduction in sexual comments, after daily treatment with conjugated estrogens 0.625 mg. Estrogen was well tolerated by both patients. DATA SOURCES: MEDLINE (January 1966-May 1998) and PsychLit (January 1974-May 1998) database searches were performed to identify case reports, letters, or clinical trials discussing estrogen use in aggressive elderly patients. CONCLUSIONS: As with previous reports, these cases suggest that conjugated estrogens may be used to reduce physical and sexual aggression associated with dementia in elderly men. Additional study is needed to determine the exact role of this alternative pharmacologic intervention.

Reliability of drug utilization evaluation as an assessment of medication appropriateness.

OBJECTIVE: To test the reliability of drug utilization evaluation (DUE) applied to medications commonly used by the ambulatory elderly. METHODS: A DUE model was developed for four domains: (1) justification for use, (2) critical process indicators, (3) complications, and (4) clinical outcomes. DUE criteria specific to use in the elderly were developed for angiotensin-converting enzyme (ACE) inhibitors and histamine2 (H2)-antagonists, and consensus was reached by an external expert panel. After pilot testing, two clinical pharmacists independently evaluated these medications, applying the DUE criteria and rating each item as appropriate or inappropriate. Interrater and intrarater reliability was assessed by using kappa statistics. RESULTS: In a sample of 208 ambulatory elderly veterans, 42 (20.2%) were taking an ACE inhibitor and 56 (26.9%) an H2-antagonist. The interrater agreement for individual domains, represented by kappa statistics, were 0.10-0.58 and 0-0.83 for ACE inhibitors and H2-antagonists, respectively. The kappa statistic for overall agreement, which considered ratings from all criteria across all domains, was 0.24 for ACE inhibitors and 0.18 for H2-antagonists. Intrarater reliability was assessed 3 months later, and kappa statistics were 0.61-0.65 (0.49 overall) and 0-0.96 (0.81 overall) for ACE inhibitors and H2-antagonists, respectively. CONCLUSIONS: Intrarater reliability for DUE was good to excellent. However, interrater reliability exhibited only marginal reproducibility, particularly where evaluators were required to use subjective judgement (i.e., complications, clinical outcomes). DUE may not be a suitable standard for assessing medication appropriateness in ambulatory elderly patients.

Reliability of a modified medication appropriateness index in ambulatory older persons.

OBJECTIVE: To evaluate the reliability of a medication appropriateness index (MAI) modified for elderly outpatients in a non-Veterans Affairs setting. DESIGN: Reliability study. SETTING: General community. PARTICIPANTS: Ten community-dwelling elderly (> 65 y) taking five or more regularly scheduled medications and participating in a university-based health service intervention study. MAIN OUTCOME MEASURES: Interrater reliability of MAI ratings of 65 medications made by two clinical pharmacists for individual items and for an overall summed score was calculated by use of kappa statistics and intraclass correlation coefficient. RESULTS: The interrater agreement for each of the individual MAI items was high for both appropriate and inappropriate ratings and ranged from 80% to 100% (overall kappa = 0.64). Overall agreement for the summed score was good (intraclass correlation = 0.80). CONCLUSIONS: The modified MAI is a reliable instrument for evaluation of medication appropriateness in a non-Veterans Affairs, ambulatory, elderly population and may provide pharmacists with a practical and standard method to evaluate patients' drug regimens and identify some potential drug-related problems.

Zolpidem for dementia-related insomnia and nighttime wandering.

OBJECTIVE: To describe two elderly patients with dementia and severe nighttime wandering in whom zolpidem restored normal sleep patterns. CASE SUMMARIES: A 90-year-old African-American woman (case 1) and an 87-year-old African-American man (case 2) presented with nighttime wandering associated with the progression of Alzheimer-like dementia. Both patients had previously not responded to bedtime regimens of benzodiazepines, trazodone (an antidepressant used for its sedative properties), and neuroleptics. Both patients averaged 2-3 hours of sleep each night. Low-dose zolpidem (5 mg hs) was initiated with only partial response. The dosage was titrated in 5-mg increments until the optimum dosage was reached for case 1 (15 mg hs) and case 2 (10 mg hs). These dosages have proven to be effective over a period of 3 months, with both patients averaging 7-8 hours of sleep each night with no apparent adverse effects. DISCUSSION: Dementia produces inversion of the circadian sleep/ wake cycle, leading to daytime sedation and nighttime wandering. Zolpidem, a nonbenzodiazepine hypnotic with proven safety and efficacy in older patients with insomnia, was well tolerated and improved sleep patterns in two patients with dementia and severe nighttime wandering. CONCLUSIONS: Zolpidem appears to be useful for restoring normal sleep patterns in elderly patients with dementia and nighttime wandering.

Therapeutic options for treating major depression, and the role of venlafaxine.

Major depression is a debilitating disorder that is often undertreated. Psychotherapy, electroconvulsive therapy, and pharmacotherapy are options for management. Tricyclic antidepressants and selective serotonin reuptake inhibitors are the cornerstones of drug therapy. Venlafaxine, a phenylethylamine antidepressant that primarily inhibits reuptake of norepinephrine and serotonin, is an alternative to those agents. It has been studied in short-term and continuation studies and appears to have efficacy similar to that of imipramine, trazodone, and fluoxetine. Moreover, venlafaxine is effective in approximately one-third of patients with treatment-resistant depression. Venlafaxine is metabolized by the P-450 enzyme system to an active metabolite O-desmethyl-venlafaxine, which is excreted renally. Nausea, somnolence, and dizziness are dose-related adverse effects that often occur with initiation of therapy. Increases in blood pressure, particularly with high dosages, also may occur. Drug-drug interactions appear to be minimal.

Establishing a family practice: a model to determine economic feasibility.

The availability of adequate health care is a major concern of urban and rural citizens. Community leaders and hospital administrators attempting to recruit family physicians and health care providers considering a specific community need a method by which they can evaluate a community's potential for supporting a first or additional primary care physician. To develop this method, a detailed survey of family practices geographically dispersed throughout Oklahoma was conducted in 1989. Data collected from family physicians and their administrative staff reflected the volume of ambulatory and hospital visits and the direct and indirect costs of the practice over the previous 12 months. Using the fixed and operating cost data, as well as number of patient visits and patient care revenue, we designed a model to project the economic feasibility of establishing a family practice in a specific community. This model can be used to project the number of visits a community can generate for a prospective family physician, as well as the direct and indirect costs, gross revenue, and net income of the practice.

Economic feasibility of a primary care practice.

To make informed career decisions, the new physician must acquire basic skills in medical management and health care economics and learn how to evaluate the potential survival and growth of a primary care practice. The authors have developed a model designed to aid physicians in determining the economic feasibility of establishing a practice in a specific community or joining an established practice.

The role of staff development in promoting BSN programs.

Staff development is undergoing rapid change in the current health care environment. One issue of critical importance is providing access to credit courses for nurses who want to obtain a Bachelor of Nursing (BSN) degree. A university and hospital collaborated to provide learning opportunities jointly for nurses to work toward completion of a BSN using the off-campus concept.