Fall-related hospitalization and facility costs among residents of institutions providing long-term care.

PURPOSE: The purpose of this study was to estimate hospital and long-term-care costs resulting from falls in long-term-care facilities (LTCFs). DESIGN AND METHODS: The study used a retrospective, pre/post with comparison group design. We used matching, based on propensity scores, to control for baseline differences between fallers and non-fallers. We estimated residents' propensity to fall from demographics, comorbidities, and reimbursement in the pre-period. The matched sample included 1,130 fallers and 1,130 non-fallers who were residents of a large, multifacility long-term-care chain. Cost estimates were based on information in the Minimum Data Set and were defined as hospital and LTCF reimbursements. We estimated fall-related costs as the difference between changes in costs for fallers and non-fallers from the pre- to post-period. RESULTS: Fallers were substantially more likely to suffer fractures and hospitalizations in the post-period than were non-fallers. Fall-related LTCF and hospital costs were $6,259 (95% confidence interval = $2,034-$10,484) per resident per year. About 60% of this amount was attributable to higher hospitalization costs. Fallers were more likely to be discharged to hospitals or to die. IMPLICATIONS: Falls in LTCFs are associated with costs of about $6,200 per resident per year. These results provide baseline estimates that one may use to estimate the cost-effectiveness of interventions to reduce fall rates.

Pharmacokinetic and pharmacodynamic alterations in the geriatric patient.

Adverse drug events (ADEs) are all too common in older patients. Although there are multiple causes for the ADEs in the elderly, alterations in pharmacokinetics (PK) and pharmacodynamics (PD) are frequent culprits. These alterations in PK and PD may be part of the normal aging process. Older patients often develop significant drug-related problems when alterations in PK and PD are not appropriately accounted for in prescribing and monitoring of medications. Clinically, the most significant PK changes that occur in aging are renal elimination and metabolism of drugs. In general, renal function declines with aging, necessitating dosage adjustments for drugs with renal-elimination pathways. The ability of the liver to metabolize certain drugs may also decline as a consequence of the aging process. From a PD standpoint, exaggerated responses are frequent, and often it is the side effects of medications that become exaggerated, rather than the therapeutic effects. Drugs affecting the central nervous system are particularly prone to PD alterations. Because of the PK and PD changes, vigilant monitoring of both therapeutic and adverse effects is mandatory in older patients. Based on PK and PD differences between middle-aged and elderly patients, there are certain medications that should almost always be avoided in older people. In addition, because older people tend to use more medications, the incidence of drug-drug interactions becomes more prevalent. Most of the drug-drug interactions that adversely impact older people involve both PK and PD mechanisms. Pharmacists and all prescribers must have a sound understanding of PK and PD effects of medications used in older people to provide optimal care and avoid preventable drug-related problems.

Development of a competency-based assessment process for advanced pharmacy practice experiences.

OBJECTIVES: To develop and implement a competency-based assessment process for the experiential component of a pharmacy education curriculum. DESIGN: A consultative process was used in the development of new assessment forms and policies, and a survey regarding student and faculty satisfaction was conducted. Information received from the survey and from consultations with faculty preceptors resulted in revision of the forms in subsequent years. ASSESSMENT: Faculty and student perceptions of the assessment process were generally positive. We were moderately successful in reducing grade inflation. The new process also provides the school with data that can be used to evaluate the effectiveness of our curriculum in preparing students for practice. CONCLUSIONS: Development and implementation of a competency-based assessment process require a considerable amount of work from dedicated faculty members. With health professions schools under pressure to provide evidence of their graduates' clinical competence, this is a worthwhile investment.

Professional practice plans: recommendations from the 2005 Council of Faculties-Council of Deans Task Force.

OBJECTIVES: Determine the degree to which AACP member schools have established professional practice plans, characterize the nature of existing practice plans, and provide recommendations on the implementation of practice plans at AACP member schools. DESIGN: Survey of CEO Deans of AACP member institutions administered via online survey instrument. RESULTS: Sixty-five schools responded, with 29 (45%) indicating that they had an active practice plan in place. Fifty-two percent of those who do no have practice plans in place anticipate having plans established within three years. A variety of revenue sources are addressed by existing practice plans including sponsored research, patient care, educational activities and consulting. CONCLUSIONS: Academic pharmacy lacks sophistication in regards to developing comprehensive professional practice plans. Colleges of pharmacy should consider differentiating plans that address monies collected from sponsored research vs. professional services. AACP should continue to monitor this topic as increasing participation by member schools is expected.

Geriatric content in pharmacotherapy and therapeutics textbooks.

OBJECTIVES: To determine the extent to which therapeutics textbooks address age-related medication information. METHODS: Criteria for 5 disease states prevalent among geriatric patients were developed based on the content of a geriatric textbook and from expert reviewers' input. The criteria were used to determine the degree to which geriatric content was addressed in 3 therapeutics textbooks. RESULTS: The therapeutics textbooks contained less than half of the critical points for 3 disease states: chronic obstructive pulmonary disease, heart failure, and diabetes mellitus (31%, 33%, and 46%, respectively). In addition, the textbooks addressed only one half to two thirds of the criteria for the remaining 2 disease states of osteoarthritis and dementia (55% and 68%, respectively). Criteria specific to the elderly were addressed less often than criteria that were important but not unique to the elderly (38% and 63%, respectively). CONCLUSIONS: Current therapeutics textbooks have significant gaps in geriatric medication information. Users of these textbooks must supplement them with primary literature or a geriatric textbook for more comprehensive medication therapy management information.

Can an educational program for residents of assisted living facilities improve drug utilization for osteoporosis?

OBJECTIVE: To examine the utilization of medications for prevention or treatment of osteoporosis in assisted living facilities and to determine the effect of an educational program for residents on changes in the use of osteoporosis medications. SETTING: Assisted living facilities. PARTICIPANTS: All residents living in 21 assisted living facilities. PRACTICE INNOVATION: Assisted living facilities were randomized into an intervention or control group. The intervention group received an education program on osteoporosis. The control group received usual care. Drug utilization for prevention or treatment of osteoporosis was determined before the intervention and at two and six months post-intervention. MAIN OUTCOME MEASURES: Drug use before and after the educational program. RESULTS: Of 1,284 residents, only 17% were receiving prescription medication for prevention or treatment of osteoporosis, and only 4.6% of residents were receiving calcium supplementation. The educational intervention did not alter osteoporosis drug use over a six-month period. CONCLUSION: A single educational program for residents of assisted living facilities did not improve drug therapy use.

Unraveling multiple complaints in an 82-year-old woman.

With this issue, The Consultant Pharmacist begins a new series, Case Studies in Geriatric Pharmacotherapy. This column will present case studies in which the pharmacist identifies actual or potential patient medication-related problems, presents an evidence-based discussion of options, and develops a patient management plan. As part of this evaluation, the pharmacist consults with both the patient's physicians and family members. Because older individuals generally consume a large number of medications, such a complex, multidisciplinary approach is critical to patient care and one that only pharmacists can provide. The growing consumption of both prescription and over-the-counter drugs by older adults increases the risk of medication-related problems. Pharmacists have an obligation to continually develop skills for identifying, treating, and preventing these medication-related problems.

Teriparatide for severe osteoporosis.

OBJECTIVE: To review the pharmacology, toxicology, pharmacokinetics, pharmacodynamics, efficacy, safety, therapeutic controversies, administration, patient counseling, and formulary recommendations for teriparatide (rDNA origin). DATA SOURCES: A MEDLINE search (1966-May 2003) of articles using the key words parathyroid hormone and osteoporosis, parathyroid hormone and fracture, and teriparatide was conducted to identify relevant literature in the English language. Additional references were obtained from bibliographies of those articles. Some clinical trial data not yet published were obtained from the manufacturer. STUDY SELECTION AND DATA EXTRACTION: All articles obtained from the data sources were reviewed; all data deemed relevant were included. DATA SYNTHESIS: Teriparatide, recombinant human parathyroid hormone (1-34) [rhPTH (1-34)], is the first anabolic agent to treat postmenopausal women with osteoporosis and men with idiopathic or hypogonadal osteoporosis who are at high risk for osteoporotic fracture. Daily subcutaneous injections of teriparatide significantly increase both spine and hip bone-mineral density (BMD) while decreasing the incidence of fractures in both women and men. Common adverse effects noted with teriparatide use were nausea, headache, dizziness, and arthralgias. An increased incidence of osteosarcoma in rats during preclinical trials with teriparatide led to a black box warning for the drug. CONCLUSIONS: Teriparatide substantially increases spine and hip BMD and may offer additional benefits to patients with severe osteoporosis. Clinical trials comparing teriparatide with other available agents to treat osteoporosis are needed to more clearly define its place in therapy. Long-term safety and efficacy are not known.

Emerging controversies in the treatment of osteoarthritis in older individuals.

OBJECTIVE: To discuss emerging controversies in the treatment of osteoarthritis, particularly as they apply to older individuals. DATA SOURCES: A MEDLINE search covering articles from 1966 to July 2003 was conducted for English-language literature on clinical trials comparing nonsteroidal anti-inflammatory drugs and acetaminophen for osteoarthritis treatment. Search terms were NSAIDs, nonsteroidal anti-inflammatory drugs, osteoarthritis, and acetaminophen. STUDY SELECTION: All controlled trials comparing acetaminophen and NSAIDs were reviewed. DATA EXTRACTION: Data from therapeutic end points comparing drugs being studied were extracted and summarized. DATA SYNTHESIS: Early studies comparing ibuprofen and acetaminophen for knee osteoarthritis identified that therapeutic end points were similar for these two drugs. These data were the basis for clinical practice guidelines published by the American College of Rheumatology in 1995 and updated in 2000. More recent clinical trials using validated instruments to measure osteoarthritis outcomes showed that NSAIDs are better than acetaminophen. There are also recent data that showed acetaminophen is equivalent to placebo in osteoarthritis outcomes. The mean age of study subjects in all the controlled trials of NSAIDs and acetaminophen was less than 65 years, making extrapolation of data from these studies to an elderly population risky. Furthermore, use of NSAIDs in older people has more risks than acetaminophen. CONCLUSIONS: Current clinical practice guidelines for osteoarthritis are based on questionable data, and new data contradicts the guideline recommendations. More studies using a geriatric population are needed to clarify if acetaminophen or NSAIDs is the better choice for initial management of osteoarthritis.

Understanding and preventing drug interactions in elderly patients.

The elderly consume a disproportionate amount of prescription and nonprescription medications. Alterations in physiology, polypharmacy, multiple prescribers, and other factors place the elderly population at risk of developing clinically significant drug-drug interactions. The incidence of potential drug-drug interactions increases with increased drug use and are responsible for numerous emergency room and physician visits. Drug interactions have been shown to cause a decline in functional abilities in older people. Drugs can interact to alter the absorption, distribution, metabolism, or excretion of a drug or interact in a synergistic or antagonist fashion altering their pharmacodynamics. Drug interactions are often clinically unrecognized and responsible for increased morbidity in elderly patients. Prudent use of medications and vigilant drug monitoring are essential to avoid drug-drug interactions.

Update on allergic rhinitis.

AR is an increasingly common inflammatory disorder. In patients with AR, abnormalities in the immune response trigger inflammatory reactions to otherwise innocuous substances, such as pollen, mold, and house dust mites. An array of environmental and pharmacologic options for AR is available, which should be tailored to the patient's symptoms and lifestyle. Investigational immunotherapies may prove valuable for patients who have an inadequate response to current therapies or experience intolerable adverse events.