European position paper on polypharmacy and fall-risk-increasing drugs recommendations in the World Guidelines for Falls Prevention and Management: implications and implementation.

Falls prevention and management in older adults is a critical global challenge. One of the key risk factors for falls is the use of certain medications. Therefore, to prevent medication-related falls, the following is recommended in the recent World Guidelines for Falls Prevention and Management: (1) assess for fall history and the risk of falls before prescribing potential fall-risk-increasing drugs (FRIDs), (2) use a validated, structured screening and assessment tool to identify FRIDs when performing a medication review, (3) include medication review and appropriate deprescribing of FRIDs as a part of the multifactorial falls prevention intervention, and (4) in long-term care residents, if multifactorial intervention cannot be conducted due to limited resources, the falls prevention strategy should still always include deprescribing of FRIDs.In the present statement paper, the working group on medication-related falls of the World Guidelines for Falls Prevention and Management, in collaboration with the European Geriatric Medicine Society (EuGMS) Task and Finish group on FRIDs, outlines its position on how to implement and execute these recommendations in clinical practice.Preferably, the medication review should be conducted as part of a comprehensive geriatric assessment to produce a personalized and patient-centered assessment. Furthermore, the major pitfall of the published intervention studies so far is the suboptimal implementation of medication review and deprescribing. For the future, it is important to focus on gaining which elements determine successful implementation and apply the concepts of implementation science to decrease the gap between research and practice.

World guidelines for falls prevention and management for older adults: a global initiative.

BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. OBJECTIVES: to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. METHODS: a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. RECOMMENDATIONS: all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. CONCLUSIONS: the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

Communication between hospitals, Family Medicine Groups and community pharmacists during transitions of care interventions.

BACKGROUND: Pharmacist-led transitions of care (TOC) interventions have been associated with improved health outcomes. Community pharmacists' (CP) TOC communications have been described whereas limited evidence is available for hospital pharmacists (HP) and none for non-dispensing pharmacists, integrated into Family Medicine Groups (FMG). OBJECTIVE: To assess information needs and perceptions about TOC communications of HP, FMG pharmacists (FMG-P) and CP and to identify optimal TOC practices and their barriers. METHODS: In a cross-sectional design, a survey was distributed via email to the 70 pharmacists who participated in a multicenter, single group, longitudinal TOC intervention study for older adults at risk of medication-related harm. All pharmacists were surveyed on their TOC practices before the TOC study, as part of usual care. Pharmacists who followed TOC study patients were also surveyed on their TOC practices during the TOC study. RESULTS: Survey responses were received from 35 pharmacists (50%), including 8 HP, 6 FMG-P and 21 CP. The frequency of communication between pharmacists of different settings increased significantly during the TOC study, with more than 80% of pharmacists reporting satisfaction with the quality of the information provided. At hospital discharge, in optimal TOC, the FMG-P and CP reported that the most important information to transfer was the reasons of hospitalization, patient weight and height, and the therapeutic intent of the medications. The main barriers to TOC implementation were the lack of clinical information about patients for FMG-P and CP and understaffing for HP. FMG-P and CP reported a similar high degree of interest in assuming responsibility for the new extended scope of practice activities of medication adjustments according to therapeutic targets or laboratory results and the implementation of a plan for gradual dose increases or drug tapering. CONCLUSIONS: The surveyed pharmacists reported an increased frequency of communication and satisfaction with the information exchanged between the pharmacists of different settings during the TOC study compared to usual care, before the study. The pharmacists extended scope of practice offers new opportunities to optimize TOC interventions.

Pharmacist-led transitions of care between hospitals, primary care clinics, and community pharmacies.

BACKGROUND: Pharmacist-led transitions of care (TOC) interventions have been described as some of the most promising interventions to reduce medication-related harm (MRH) in older adults. This study analyzed the feasibility of pharmacist-led TOC interventions between hospitals, multidisciplinary primary care clinics (PCC), and community pharmacies. METHODS: Adults aged 65 years and older at risk of MRH in three regions of Quebec, Canada, with contrasting contexts of care based on university affiliation were recruited in this multicenter, single arm, and prospective intervention cohort. The hospital pharmacist developed the pharmaceutical care plan in collaboration with the hospital physician and transferred this plan with the hospitalization summary, at hospital discharge, to the PCC family physician and to the community and PCC pharmacists. A consultation with the community pharmacist was scheduled within seven days of hospital discharge and with the PCC pharmacist when appropriate. Feasibility outcomes included the time to complete the interventions and their location. RESULTS: The 123 eligible patients had a mean age of 78.5 years, and 63.4% were females. The most frequent inclusion criterion was 10 medications or more, including one high-risk medication for 90 patients (73%). Recruitment in one region was stopped after three months due to unsuccessful recruitment of key PCC. The hospital pharmacist interventions took a median of 165 min. The first consultations of the PCC and community pharmacists took a median of 15 and 50 min. Among the 96 patients with a post-discharge pharmacist follow-up, 23 (24.0%) had a consultation with a PCC pharmacist, with 65.2% of the consultations conducted at the PCC. The community pharmacists conducted a consultation with 88 patients (93%), with more than 70% of consultations conducted by phone. CONCLUSION: Our study showed the feasibility of pharmacist-led TOC interventions between hospitals, PCC, and community pharmacies and detailed the novel role that PCC pharmacists played in optimizing TOC interventions.

New horizons in falls prevention and management for older adults: a global initiative.

BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects both on quality of life and functional independence and are associated with increased morbidity, mortality and health care costs. Current clinical approaches and advice from falls guidelines vary substantially between countries and settings, warranting a standardised approach. At the first World Congress on Falls and Postural Instability in Kuala Lumpur, Malaysia, in December 2019, a worldwide task force of experts in falls in older adults, committed to achieving a global consensus on updating clinical practice guidelines for falls prevention and management by incorporating current and emerging evidence in falls research. Moreover, the importance of taking a person-centred approach and including perspectives from patients, caregivers and other stakeholders was recognised as important components of this endeavour. Finally, the need to specifically include recent developments in e-health was acknowledged, as well as the importance of addressing differences between settings and including developing countries. METHODS: a steering committee was assembled and 10 working Groups were created to provide preliminary evidence-based recommendations. A cross-cutting theme on patient's perspective was also created. In addition, a worldwide multidisciplinary group of experts and stakeholders, to review the proposed recommendations and to participate in a Delphi process to achieve consensus for the final recommendations, was brought together. CONCLUSION: in this New Horizons article, the global challenges in falls prevention are depicted, the goals of the worldwide task force are summarised and the conceptual framework for development of a global falls prevention and management guideline is presented.

Pharmacist-led transitions of care for older adults at risk of drug-related problems: A feasibility study.

BACKGROUND: Transitions of care (TOC) is one of three key action areas identified in the World Health Organization (WHO)'s third Global Patient Safety Challenge, Medication Without Harm, released in 2017. Systematic reviews have shown that TOC interventions can improve health outcomes, although few studies have evaluated the role of the community pharmacist. OBJECTIVE: To evaluate the feasibility of a pharmacist-led TOC intervention for older adults at risk of drug-related problems. METHODS: Pragmatic feasibility study conducted in hospital and community pharmacies in a health region of Quebec, Canada. The interventions consisted of a pharmaceutical care plan developed by the hospital pharmacist and transferred at hospital discharge to the patients' community pharmacist, who completed patient consultations in the week following discharge and monthly for six months thereafter. Feasibility evaluations included recruitment, retention, time required, types of interventions, and modified classes of medications, based on clinical data entered in an electronic health record accessible to clinicians in all settings. RESULTS: Of the 90 recruited patients, 76 were discharged with a pharmaceutical care plan. The mean age of these 76 subjects was 79.5 years, and 52.6% were female. The most frequent inclusion criteria were 15 or more medications (57.9%), two or more emergency department visits (past three months), or one or more hospitalization (past twelve months) (42.1%). The hospital pharmacist interventions took a mean time of 222 min. The community pharmacist interventions took a mean time of 52 min and 32 min for the first and subsequent visits, respectively. Therapeutic goals were documented for 60.5% of patients. CONCLUSIONS: This study shows the feasibility of implementing a pharmacist-led TOC intervention in the Canadian context. Development of the TOC model in three health regions is currently being pursued along with the inclusion of primary care clinics who recently added pharmacists to their interdisciplinary teams.

Medication appropriateness on an acute geriatric care unit: the impact of the removal of a clinical pharmacist.

BACKGROUND: evidence is largely available indicating benefits to adding a pharmacist on acute care wards. The benefits of maintaining pharmacotherapeutic consultant services on a geriatric ward remain unexplored. OBJECTIVES: to determine the impact of the removal of a clinical pharmacist from an acute geriatric ward on patients' Medication Appropriateness Index (MAI) scores, admission-related outcomes and drug burdens. METHODS: researchers consulted the archives for records of patients admitted to the geriatric care unit before and after the pharmacist's withdrawal. The primary outcome of differential MAI scores and secondary outcomes of rehospitalisations, emergency department visits, durations of hospitalisation and differential drug count were compared pre- and post-intervention. An interrupted time series analysis regression model was used for the primary outcome. RESULTS: a total of 305 patients admitted before (n = 208) and after (n = 97) the pharmacist's withdrawal were included in the study. The intervention had a significant impact on the primary outcome, increasing the relative differential MAI score (adjusted mean) by 9.3 points (95% confidence interval 3.9-14.6). As for the secondary outcomes, differences in admission-related outcomes were non-significant but the mean differential drug count significantly increased post-intervention from 0.02 to 1.36 (P < 0.001). CONCLUSION: the removal of the pharmacist led to an increase in inappropriate drug prescription. Careful consideration should be given to decisions regarding the removal of the pharmacist from acute geriatric care teams.

Knowledge Translation Strategy to Reduce the Use of Potentially Inappropriate Medications in Hospitalized Elderly Adults.

OBJECTIVES: To evaluate the effect of a knowledge translation (KT) strategy to reduce potentially inappropriate medication (PIM) use in hospitalized elderly adults. DESIGN: Segmented regression analysis of an interrupted time series. SETTING: Teaching hospital. PARTICIPANTS: Individuals aged 75 and older discharged from the hospital in 2013/14 (mean age 83.3, 54.5% female). INTERVENTION: The KT strategy comprises the distribution of educational materials, presentations by geriatricians, pharmacist-physician interventions based on alerts from a computerized alert system, and comprehensive geriatric assessments. MEASUREMENTS: Rate of PIM use (number of patient-days with use of at least one PIM/number of patient-days of hospitalization for individuals aged ≥75). RESULTS: For 8,622 patients with 14,071 admissions, a total of 145,061 patient-days were analyzed. One or more PIMs were prescribed on 28,776 (19.8%) patient-days; a higher rate was found for individuals aged 75 to 84 (24.0%) than for those aged 85 and older (14.4%) (P < .001), and in women (20.8%) than in men (18.6%) (P < .001). The drug classes most frequently accounting for the PIM were gastrointestinal agents (21%), antihistamines (18%), and antidepressants (17%). An absolute decrease of 3.5% (P < .001) of patient-days with at least one PIM was observed immediately after the intervention. CONCLUSION: A KT strategy resulted in decreased use of PIM in elderly adults in the hospital. Additional interventions will be implemented to maintain or further reduce PIM use.

A Pharmacist-Physician Intervention Model Using a Computerized Alert System to Reduce High-Risk Medication Use in Elderly Inpatients.

BACKGROUND: Prescription is a complex challenge facing clinicians caring for elderly inpatients. Potentially inappropriate medication (PIM) use frequently leads to adverse drug events and geriatric syndromes. Strategies to reduce PIM use are thus urgently needed. OBJECTIVES: The objectives of this study were to assess (1) the applicability of a pharmacist-physician intervention model to reduce the use of high-risk medications; and (2) the clinical relevance of the alerts generated by a computerized alert system (CAS). METHODS: The study was conducted in patients aged 65 years or older admitted to a teaching hospital between April and June 2014. In the intervention model, the pharmacist determined the clinical relevance of the Beers criteria-based CAS alerts, analyzed the patient's pharmacotherapy, and developed a geriatric pharmacotherapeutic plan to be discussed with the treating physician. The main outcome was the change rate, defined as the number of patient-days with a change in at least one medication out of the number of patient-days with a pharmacist intervention. RESULTS: The CAS identified at least one alert in 200 patient-days, i.e., 4.3% of screened patient-days. In 74.5% of those patient-days, at least one alert was judged to be clinically relevant. The change rate was 77.7%. The most frequent changes were drug discontinuation (42.4%) and dose reduction (29.1%). The inpatient geriatric consultation team was involved in only 24% of the hospitalizations with at least one change in medication. CONCLUSION: The intervention model reduced high-risk medication use in older inpatients. Most of the vulnerable inpatients identified by CAS alerts would not have otherwise had a geriatric medication review.

Description of a systematic pharmaceutical care approach intended to increase the appropriateness of medication use by elderly patients.

BACKGROUND & AIMS: The pharmaceutical care practice represents a model of responsible pharmacist involvement in the pharmacotherapy optimization of various population groups, including the elderly, known to be at risk for drug-related problems. Romanian pharmacists could use validated pharmaceutical care experiences to confirm their role as health-care professionals. This descriptive research presents the application in two real and different environments of practice of a structured pharmaceutical care approach conceived as the basis for a medication review activity and aiming at the identification and resolution of the drug related problems in the elderly. PATIENTS AND METHODS: Two patients with similar degree of disease-burden complexity, receiving care in different health-care environments (The Geriatric Ward of the Royal Victoria Hospital from the McGill University Health Centre in Montréal, Québec, Canada, in November 2010, and an urban nursing-home facility in Cluj-Napoca, Romania, in March 2011), were chosen for the analysis. One clinical pharmacist suggested solutions for the management of each of the active drug-related problems identified, using the systematic pharmaceutical care approach and specific published geriatric pharmacotherapy recommendations. The number of the drug-related problems identified and the degree of the care-team acceptance of the pharmacists' solutions were noted for each patient. RESULTS: The pharmacist found 6 active drug-related problems for the hospitalized patient (72 year-old, Chronic Disease Score 9) and 7 potential ones for the nursing-home resident (79 year-old, Chronic Disease Score 8), involving misuse, underuse and overuse of medications. Each patient had 3 geriatric syndromes at baseline. The therapy changes suggested by the pharmacist were implemented for the hospitalized patient, through collaboration with the health-care team. For the nursing home resident, the pharmacist identified the need for additional 6 medications and safety and efficacy arguments to cease 7 initial therapies, simplifying the therapeutic daily schedule (from 24 daily doses to 15). CONCLUSION: The pharmacist's potential contribution to the optimization of the Romanian elderly patients' pharmacotherapy needs further exploration, as potential drug related problems reported as characteristic for this population were easily identified. The presented structured and validated model of pharmaceutical care approach could be used to this end. Its dissemination and use could be encouraged along with the enhancement of pharmacotherapy information and care team collaboration skills.

Prescribing opioids in older people.

People are living to older age. Demographic pressures are driving change. Opiate analgesics are the most powerful known pain relievers. Persistent pain, both cancer and non-cancer types is frequent in older adults. The use of opioid analgesics is appropriate in the treatment of moderate to severe persistent pain. The challenge of prescribing opioids in older adults is to understand the factors involved in making appropriate choices and monitoring the beneficial effects of pain relief while managing the side-effects. This article will review the current concepts, evidence and controversies surrounding opiate use in the elderly. An approach is outlined which involves: pain assessment, screening for substance abuse potential, deciding whether you are able to treat your patient without help, starting treatment, monitoring effectiveness of pain control and managing opioid-associated side-effects. The goal of pain management using opioids is the attainment of improved function and quality of life.

Medication-related falls in the elderly: causative factors and preventive strategies.

People are living to older age. Falls constitute a leading cause of injuries, hospitalization and deaths among the elderly. Older people fall more often for a variety of reasons: alterations in physiology and physical functioning, and the use (and misuse) of medications needed to manage their multiple conditions. Pharmacological factors that place the elderly at greater risk of drug-related side effects include changes in body composition, serum albumin, total body water, and hepatic and renal functioning. Drug use is one of the most modifiable risk factors for falls and falls-related injuries. Fall-risk increasing drugs (FRIDs) include drugs for cardiovascular diseases (such as digoxin, type 1a anti-arrhythmics and diuretics), benzodiazepines, antidepressants, antiepileptics, antipsychotics, antiparkinsonian drugs, opioids and urological spasmolytics. Psychotropic and benzodiazepine drug use is most consistently associated with falls. Despite the promise of a more favourable side-effect profile, evidence shows that atypical antipsychotic medications and selective serotonin reuptake inhibitor antidepressants do not reduce the risk of falls and hip fractures. Despite multiple efforts with regards to managing medication-associated falls, there is no clear evidence for an effective intervention. Stopping or lowering the dose of psychotropic drugs and benzodiazepines does work, but ensuring a patient remains off these drugs is a challenge. Computer-assisted alerts coupled with electronic prescribing tools are a promising approach to lowering the risk of falls as the use of information technologies expands within healthcare.

Applicability of an adapted medication appropriateness index for detection of drug-related problems in geriatric inpatients.

BACKGROUND: High drug consumption by older patients and the presence of many drug-related problems require careful assessment of drug therapy, for which a structured approach is recommended. OBJECTIVE: The purpose of our study was to evaluate the applicability of an adapted version of the Medication Appropriateness Index (MAI) in 50 geriatric inpatients at the time of admission. METHODS: We reviewed, for 432 prescribed drugs, indication, right choice, dosage, directions, drug-disease interactions, drug-drug interactions, and duration of therapy. In addition, adverse drug reactions were evaluated, resulting in 8 questions per drug. MAI scores were attributed independently by a geriatrician and by a clinical pharmacist, and differences between them were assessed. Furthermore, the relationship between MAI score and drug-related hospital admission was explored. RESULTS: Mean summed MAI scores of 13.7 according to the geriatrician and 13.6 according to the pharmacist were obtained. The highest scores were found for drugs for the central nervous and the urinary tract system; the highest scores per question were detected for right choice, adverse drug reactions, and drug-drug interactions. A good agreement between the scores of the geriatrician and the pharmacist was found: intraclass correlation coefficient was 0.91 and overall κ value was 0.71. A significantly higher MAI score was found for drug-related hospital admissions (P = 0.04 for the geriatrician and P = 0.03 for the pharmacist). CONCLUSIONS: This adapted MAI score seems useful for detection of drug-related problems in geriatric inpatients and reliable with a low inter-rater variability and positive correlation between high score and drug-related hospital admission. We consider further application of the adapted MAI for teaching and training of clinical pharmacists, and as a systematic approach for detection of drug-related problems by the clinical pharmacists in our hospital.

Learning while having fun: the use of video gaming to teach geriatric house calls to medical students.

Although most health professionals perform home visits, there is not a structured method for performing them. In addition, in-training health professionals' exposure to home visits is limited for logistical reasons. A new method for medical students to learn how to perform an effective home visit was developed using an instructional video game. It was expected that students would learn the principles of a home visit using a video game while identifying the usefulness of video gaming (edutainment) in geriatrics education. A video game was created simulating a patient's house that the students were able to explore. Students played against time and distracters while being expected to click on those elements that they considered to be risk factors for falls or harmful for the patient. At the end of the game, the students received feedback on the chosen elements that were right or wrong. Finally, evaluation of the tool was obtained using pre- and posttests and pre- and postexposure feedback surveys. Fifty-six fourth-year medical students used the video game and completed the tests and the feedback surveys. This method showed a high level of engagement that is associated with improvement in knowledge. Additionally, users' feedback indicated that it was an innovative approach to the teaching of health sciences. In summary, this method provides medical students with a fun and structured experience that has an effect not only on their learning, but also on their understanding of the particular needs of the elderly population.

The challenge of managing drug interactions in elderly people.

Drug therapy is essential when caring for elderly patients, but clearly it is a double-edged sword. Elderly patients are at high risk of having drug interactions, but the prevalence of these interactions is not well documented. Several types of interactions exist: drug-drug, drug-disease, drug-food, drug-alcohol, drug-herbal products, and drug-nutritional status. Factors such as age-related changes in pharmacokinetics and pharmacodynamics, frailty, interindividual variability, reduced homoeostatic mechanisms, and psychosocial issues need to be considered when drug interactions are assessed. Software can help clinicians to detect drug interactions, but many programmes have not been updated with the evolving knowledge of these interactions, and do not take into consideration important factors needed to optimise drug treatment in elderly patients. Any generated recommendations have to be tempered by a holistic, geriatric, multiprofessional approach that is team-based. This second paper in a series of two on prescribing in elderly people proposes an approach to categorise drug interactions, along with strategies to assist in their detection, management, and prevention.

To treat or not to treat, that is the question: proceedings of the Quebec symposium for the treatment of osteoporosis in long-term care institutions, Saint-Hyacinthe, Quebec, November 5, 2004.

OBJECTIVES: Patients in long-term care institutions (LTCI) are especially at risk for osteoporotic fractures owing to their lack of mobility, poor nutrition, and limited sun exposure. Previous reports have shown that osteoporosis is underdiagnosed and undertreated in LTCI despite the high incidence of osteoporotic fractures in these settings. This document has been developed to assist clinicians practicing in LTCI with the diagnosis and treatment of osteoporosis in their institutionalized patients. These proceedings offer an overview of the particular characteristics of patients at LTCI. Management strategies include both nonpharmacological and pharmacological interventions for the prevention and treatment of osteoporotic fractures in very frail older subjects. PARTICIPANTS: This guide is an edited review of presentations and discussions held by specialists in osteoporosis in the elderly together with physicians and pharmacists practicing in LTCI in the province of Quebec. This symposium was held in Saint-Hyacinthe, Quebec on November 5, 2004. VALUES: The value of a given diagnostic test or treatment option was determined based on the clinical experiences and opinions of the participants and a review of the literature from an evidence-based perspective. RECOMMENDATIONS: All patients located at LTCI are at potential risk for osteoporotic fractures. Global interventions should include vitamin D, calcium, and a comprehensive exercise program. In patients who are at high risk for osteoporotic fractures or with previous fractures, pharmacological treatment should be started. VALIDATION: These recommendations were approved during the final plenary of the symposium. All the prevailing opinions were summarized and included in this article.

Olanzapine prolongs cardiac repolarization by blocking the rapid component of the delayed rectifier potassium current.

Prolongation of the QT interval has been observed during treatment with olanzapine, a thienobenzodiazepine antipsychotic agent. Our objectives were 1) to characterize the effects of olanzapine on cardiac repolarization and 2) to evaluate effects of olanzapine on the major time-dependent outward potassium current involved in cardiac repolarization, namely I(Kr) (I(Kr): rapid component of the delayed rectifier potassium current).Isolated, buffer-perfused guinea pig hearts (n = 40) were stimulated at different pacing cycle lengths (150-250 msec) and exposed to olanzapine at concentrations ranging from 1 to 100 microM. Olanzapine increased monophasic action potential duration measured at 90% repolarization (MAPD90) in a concentration-dependent manner by 6.7 +/- 0.7 msec at 3 microM but by 26.0 +/- 4.3 msec at 100 microM (250 msec cycle length). Increase in MAPD(90) was also reverse frequency dependent; 30 microM olanzapine increased MAPD90 by 28.0 +/- 6.2 msec at a pacing cycle length of 250 msec but by only 18.9 +/- 2.2 msec at a pacing cycle length of 150 msec. Experiments in HERG-transfected (HERG: human ether-a-gogo-related gene) HEK293 cells (n = 36) demonstrated concentration-dependent block of the rapid component (I(Kr)) of the delayed rectifier potassium current: tail current was decreased 50% at olanzapine 3.8 microM. Olanzapine possesses direct cardiac electrophysiological effects similar to those of class III anti-arrhythmic drugs. These effects were observed at concentrations that can be measured in patients under conditions of impaired drug elimination such as renal or hepatic insufficiency, during co-administration of other CYP1A2 substrates/inhibitors or after drug overdose. These results offer a new potential explanation for QT prolonging effects observed during olanzapine treatment in patients.

To treat or not to treat, that is the question: proceedings of the Quebec Symposium for the Treatment of Osteoporosis in Long-term Care Institutions, Saint-Hyacinthe, Quebec, November 5, 2004.

OBJECTIVES: Patients in long-term care institutions (LTCI) are especially at risk for osteoporotic fractures owing to their lack of mobility, poor nutrition, and limited sun exposure. Previous reports have shown that osteoporosis is underdiagnosed and undertreated in LTCI despite the high incidence of osteoporotic fractures in these settings. This document has been developed to assist clinicians practicing in LTCI with the diagnosis and treatment of osteoporosis in their institutionalized patients. These proceedings offer an overview of the particular characteristics of patients at LTCI. Management strategies include both nonpharmacological and pharmacological interventions for the prevention and treatment of osteoporotic fractures in very frail older subjects. PARTICIPANTS: This guide is an edited review of presentations and discussions held by specialists in osteoporosis in the elderly together with physicians and pharmacists practicing in LTCI in the province of Quebec. This symposium was held in Saint-Hyacinthe, Quebec on November 5, 2004. VALUES: The value of a given diagnostic test or treatment option was determined based on the clinical experiences and opinions of the participants and a review of the literature from an evidence-based perspective. RECOMMENDATIONS: All patients located at LTCI are at potential risk for osteoporotic fractures. Global interventions should include vitamin D, calcium, and a comprehensive exercise program. In patients who are at high risk for osteoporotic fractures or with previous fractures, pharmacological treatment should be started. VALIDATION: These recommendations were approved during the final plenary of the symposium. All the prevailing opinions were summarized and included in this article.

Implementation of ward-based clinical pharmacy services in Belgium--description of the impact on a geriatric unit.

BACKGROUND: Patient-centered clinical pharmacy services are still poorly developed in Europe, despite their demonstrated advantages in North America and the UK. Reporting European pilot experiences is, therefore, important to assess the usefulness of clinical pharmacy services in this specific context. OBJECTIVE: To report the results of the first implementation of Belgian clinical pharmacy services targeting patients at high risk of drug-related problems. METHODS: An intervention study was conducted by a trained clinical pharmacist providing pharmaceutical care to 101 patients (mean age 82.2 y; mean +/- SD number of prescribed drugs 7.8 +/- 3.5) admitted to an acute geriatric unit, over a 7 month period. All interventions to optimize prescribing, and their acceptance, were recorded. An external panel (2 geriatricians, 1 clinical pharmacist) assessed the interventions' clinical significance. Persistence of interventions after discharge was assessed through telephone calls. RESULTS: A total of 1066 interventions were made over the 7 month period. The most frequent drug-related problems underlying interventions were: underuse (15.9%), wrong dose (11.9%), inappropriate duration of therapy (9.7%), and inappropriate choice of medicine (9.6%). The most prevalent consequences were to discontinue a drug (24.5%), add a drug (18.6%), and change dosage (13.7%). Acceptance rate by physicians was 87.8%. Among interventions with clinical impact, 68.3% and 28.6% had moderate and major clinical significance, respectively. Persistence of chronic treatment changes 3 months after discharge was 84%. CONCLUSIONS: Involving a trained clinical pharmacist in a geriatric team led to clinically relevant and well-accepted optimization of medicine use. This initiative may be a springboard for further development of clinical pharmacy services.