Clinical and regulatory concerns in Alzheimer's disease management: role of the pharmacist.

The role of the pharmacist in managing Alzheimer's disease (AD) is discussed. Health-system pharmacists can play a critical role in the management of AD, provided they remain up-to-date on new drug therapies, recent clinical findings, and educational resources for caregivers and families. Pharmacists in a long-term-care setting must know and apply the federal regulations set forth in the Omnibus Budget Reconciliation Act of 1987. Pharmacists have an excellent opportunity to optimize pharmacotherapy by carefully reviewing treatment regimens to identify potential drug-related problems. These might include improper drug selection, inappropriate dosage, adverse drug reactions, and interactions. Pharmacists should encourage the use of cholinesterase inhibitors in patients with mild to moderate AD and should monitor such therapy by interacting with nurses, physicians, and caregivers. AD patients not only suffer cognitive decline but may have psychiatric and behavioral disturbances, which can be especially problematic for the caregiver. When possible, these disturbances should be managed by nonpharmacologic strategies, such as environmental changes and behavior modification. The pharmacist can recommend and monitor the use of psychotropic agents for psychiatric and behavioral symptoms that do not respond to nonpharmacologic strategies. These drugs must be carefully selected and monitored, and gradual dosage reductions must be periodically attempted. Finally, pharmacists should provide caregivers and families with education, emotional support, and referrals. Pharmacists who are well-grounded in the regulatory and clinical issues surrounding AD can play a major role in managing this illness.

An evaluation of antihypertensive prescribing practices.

We evaluated the management of patients with hypertension (including drug prescribing) by US physicians, compared their prescribing to National Institutes of Health (NIH) guidelines, and compared the pharmacoeconomics of the prescribed antihypertensive drugs. A 1991 national US database, using physician-patient encounter forms, was our data source. Results showed that physicians generally met the NIH guidelines regarding diagnostic/screening services, patient counselling/education, antihypertensive drug prescribing and follow-up. Two areas should be the foci of continuing medical education for US physicians. Firstly, physicians need to be reminded that centrally acting alpha 2-agonists are optimally used as supplemental antihypertensive drugs rather than as initial agents, which is how some physicians utilised them. Secondly, if once-daily administration is used to promote patient compliance, physicians should be aware that, of the frequently prescribed first-line antihypertensive drugs, hydrochlorothiazide, chlorthalidone and atenolol presently have substantially less expensive once-daily dosage forms than other diuretics or beta-blockers, calcium antagonists or ACE inhibitors.

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.

The clinical use of histamine-2 receptor antagonists.

Histamine-2 receptor antagonists have been available for fifteen years for the treatment of peptic ulcer disease and related disorders. While very safe, clinicians need to know correct dosing guidelines, drug interactions, and side effect profiles. Long-term therapy should be reserved for patients at high risk of recurrence.

Alternate drugs.

It is important to consider a number of factors when deciding on drug therapy for elderly patients. The principles of efficacy, side effect profile, ease of administration, interaction with other drugs or concomitant illness, cost, and constant reevaluation of the need for continued treatment should be remembered for any treatment. In many cases the ideal drug may be initially no drug at all. A number of alternative drugs are available for most conditions, and the drug of choice for the elderly may actually be one of these alternative agents. We have attempted to consider these basic principles as they may be applied in making a decision for ideal drug therapy and for alternative therapies for elderly patients.

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.

A flexible module for teaching quality assurance and drug prescribing review concepts.

A case-approach, educational module is described that was designed with the necessary flexibility for teaching a variable number of quality assurance and drug prescribing review concepts to different types of students in different types of teaching situations. Module evaluation showed effectiveness as well as areas needing improvement.

Audit of digoxin prescribing in ambulatory patients.

Digoxin prescribing for ambulatory patients with uncomplicated congestive heart failure in normal sinus rhythm (UCHF) was evaluated. The audit was conducted at a hospital primary care clinic and was performed retrospectively over a recent 2-year period. The audit focused on the discontinuance of digoxin prescribing and the attendant monitoring necessary. There was 34 patients prescribed digoxin during the study period who were classified as UCHF. Of these, 23 (68%) met our a priori criteria for digoxin discontinuance. However, only three of the 23 were discontinued and none met the criteria for proper follow-up. With regard to monitoring, the average patient was seen once every 2 months, but in fewer than half of the visits the patient was assessed on basic subjective and objective parameters of CHF status and digoxin toxicity. These results are being used in an educational program for the clinic physicians who before the audit had perceived their care of digoxin patients to be optimal.

Drug prescribing for ambulatory patients 85 years of age and older.

Drug prescribing for ambulatory patients greater than or equal to 85 years of age was studied using data from the 1980 National Ambulatory Medical Care Survey (NAMCS) on office visits to physicians. NAMCS is a survey by the US National Center for Health Statistics, which collected information on office visits and extrapolated the results to the US population. Of the 575.7 million office visits by all ages, 6.8 million (1 per cent) were by persons greater than or equal to 85 years of age, and 64 per cent involved females. Ninety per cent of the total office visits of those greater than or equal to 85 years were with a physician who had seen them before; 94 per cent were with MDs as compared with DOs; 56 per cent were with general practitioners or internists; and 95 per cent had some type of follow-up planned. The most frequent duration of the office visit was 11-15 minutes (36 per cent). The most frequent diagnostic class was diseases of the circulatory system. The survey physicians were asked to list all drugs, new or already in use by the patient, that were ordered, administered, or prescribed during the visit. The authors converted the drug brand names to their nonproprietary or generic name component(s); each active ingredient of combination products was treated as a separate drug entity. All drug analyses used generic names. Thirty-two per cent of visits did not involve the use of any drug, 21 per cent involved one drug; 12 per cent, two drugs; and 16 per cent, three drugs. Cardiovascular-renal drugs were the most frequently mentioned. One-third of the visits involved the use of one or more drugs that have psychologic effects, either intended or as side effects. Three per cent of the office visits involved the use of two or more drugs that had the potential for clinically important interactions.