Medication Regimen Complexity Index in the Elderly in an Outpatient Setting: A Literature Review.

Objective To review current literature reporting outcomes associated with utilization of the Medication Regimen Complexity Index (MRCI) with older adults in an outpatient setting. Data sources The National Library of Medicine via PubMed, International Pharmaceutical Abstracts, and the Cochrane Database were used to identify clinical trials evaluating outcomes associated with utilization of the MRCI. The medical subject heading terms "geriatrics" and "medication adherence" were used in combination with key terms "medication regimen complexity index" and "medication complexity." Study selection/data extraction Seventy-five articles met the search criteria and were reviewed. Studies were included if they had MRCI-related outcomes and were performed in patients 60 years of age and older in an outpatient setting. Eleven articles met the stated criteria. Data synthesis Higher MRCI scores may be associated with increased mortality rates, medication nonadherence, and unplanned hospitalizations; however, when compared with medication number, MRCI did not better predict increased medication nonadherence and unplanned hospitalizations. Conclusion The MRCI is a useful tool to determine medication complexity; however, current literature is limited by its observational design. Also, MRCI does not take into account potential factors such as high-risk medications and comorbid conditions, which may affect MRCI scores; therefore, additional trials are warranted before suggesting pharmacists implement this tool in their everyday practice.

Adherence to Insulin Therapy.

IN BRIEF Six million people with diabetes use insulin either alone or in combination with an oral medication. Many barriers exist that lead to poor adherence with insulin. However, there is an underwhelming amount of data on interventions to address these barriers and improve insulin adherence. Until pharmacological advancements create easier, more acceptable insulin regimens, it is imperative to involve patients in shared decision-making.

Aspirin Use for the Primary Prevention of Cardiovascular Disease in the Elderly.

OBJECTIVE: This article aims to use the available evidence assessing aspirin for primary prevention of cardiovascular (CV) events in the elderly to determine its appropriate use. DATA SOURCES: A literature search of clinical trials and meta-analyses was conducted using MEDLINE and PubMed with the search terms aspirin, bleeding, CV events, elderly, geriatrics, hemorrhage, myocardial infarction (MI), primary prevention, and stroke. STUDY SELECTION/DATA EXTRACTION: Twelve hundred fourteen (1,214) articles were initially found, and 55 were reviewed. These articles assessed the use of aspirin for primary prevention of CV events. Only trials comparing aspirin with placebo, a non-antiplatelet, or a non-anticoagulant were included in this review. Of the articles reviewed, 10 met the stated criteria. DATA SYNTHESIS: It is well documented that the risk of CV events increases as patients age. Primary prevention of these events with aspirin may be beneficial in some patients. Currently, a specific recommendation for the use of aspirin for primary prevention in the geriatric population is not available. This paper reviews the available evidence for primary prevention of CV disease. This population is under-represented in the literature, making it challenging to apply the study findings. CONCLUSION: Aspirin may be considered for the primary prevention of CV events in the elderly population. Because of the lack of data in patients 80 years of age and older, it is difficult to make a decision on the initiation of aspirin therapy in this population. Additional research is necessary to better balance the risk versus benefit of this treatment option.

Experiential Pharmacy Education During a Pandemic: Lessons Learned.

The COVID-19 pandemic has radically changed how the world operates and introduced a multitude of unprecedented challenges for all health professionals, especially for those responsible for training learners, including pharmacy residents and students. Due to density and social distancing restrictions, many pharmacy schools and residency programs had to transition to virtual experiential learning-with little to no existing literature, structure, or adequate time for planning. This article offers a variety of approaches to ensure that pharmacy learners meet accreditation requirements, engage in interprofessional education and collaboration, reflect on their learning, prioritize self-care, and are adequately prepared to enter geriatric pharmacy practice despite current challenges with the COVID-19 pandemic. Authors address both challenges, as well as opportunities to expand future experiential education for all pharmacy learners.

Evaluation of Antibiotic Utilization in a Rural, Outpatient Clinic: An Antimicrobial Stewardship Initiative.

BACKGROUND: Antibiotics are commonly prescribed for uncomplicated urinary tract infection (UTI) and acute otitis media (AOM) and may be unnecessary at times. The aim of this study was to evaluate prescribing practices for UTIs and AOM in a rural ambulatory care setting and to identify areas for improvement. METHODS: In a single-center, retrospective review conducted at a rural clinic, patients diagnosed with uncomplicated UTI and AOM were included. Patients were identified by International Classification of Diseases, Tenth (ICD-10) codes, and data were collected for visits between January 1, 2017, and December 31, 2017. The primary outcome was to assess adherence of antimicrobial prescribing to current treatment guidelines. RESULTS: Of the 76 patients identified, 28 met inclusion criteria. Of the 28 patients, 75% received an agent recommended first line in the treatment guidelines, and 18 of the 21 received a recommended dose. Only 17% of patients were prescribed an appropriate duration of treatment. CONCLUSION: Opportunities exist for antimicrobial stewardship interventions for uncomplicated UTIs and AOM. Prescribers are not consistently adhering to guidelines in regard to antibiotic choice, dose, or duration. Additional education and stewardship interventions are crucial considering the increased prevalence of antimicrobial resistance.

Management of Direct-Acting Oral Anticoagulants Surrounding Dental Procedures With Low-to-Moderate Risk of Bleeding.

The purpose of this article is to review the available evidence regarding how to safely manage direct-acting oral anticoagulant (DOAC) therapy in patients requiring dental procedures with low-to-moderate risk of bleeding. A literature search was performed using MEDLINE and PubMed. Each author performed an independent search to ensure all pertinent articles were identified. The reference sections of each article were also reviewed. Pertinent articles were evaluated by each author for inclusion. Articles were eligible for inclusion if the participants were taking DOAC therapy surrounding a dental procedure known to have low-to-moderate risk of bleeding. Studies could be prospective or retrospective and included case reports, case series, and clinical trials. Articles were excluded if they assessed dental procedures known to carry a high risk of bleeding or were review articles. Twenty-five articles were identified, 5 of which met inclusion criteria including 2 case series, 1 retrospective study, and 2 prospective trials. Variation in the management of DOAC therapy surrounding these procedures was found. Among patients undergoing low-to-moderate risk dental procedures while receiving DOAC therapy, bleeding rates were low regardless of whether the DOAC was held or continued surrounding the procedure. Documented bleeding was mild and easily controlled by local hemostatic measures. Patients can safely continue DOAC therapy surrounding these dental procedures.

Total anticholinergic burden and survival within a cohort of elderly Mexican Americans.

AIM: Studies examining the association between mortality and anticholinergic burden in the geriatric population are conflicting and are absent in the Mexican American population. The present study aimed to determine whether higher anticholinergic burden increases mortality in a cohort representative of community-based older Mexican Americans in the USA. METHODS: This retrospective cohort database study used the Hispanic Established Populations for the Epidemiologic Study of the Elderly cohort. The primary outcome, mortality, was assessed beginning at the second interview in 1995 until the fifth interview in 2005. Medications were classified for anticholinergic burden according to the modified-Anticholinergic Drug Scale and were summed across all reported medications creating a measure of total anticholinergic burden. Anticholinergic burden was tested for association with mortality using survival analysis. RESULTS: The 1497 older adults reporting medication usage were included. Survival analysis showed a statistically significant (P < 0.05) relationship between anticholinergic burden and increased mortality. CONCLUSIONS: Anticholinergic burden is associated with increased mortality in Southwestern Mexican American older adults who report taking prescription or non prescription medications. These findings suggest that anticholinergic burden might be a risk factor for mortality in this selected population, with additional studies required to further define the risk. Geriatr Gerontol Int 2017; 17: 1515-1521.