Descriptive analysis of concomitant prescription medication patterns from 1999 to 2004 among US women receiving daily or weekly oral bisphosphonate therapy.

BACKGROUND: To improve medication-taking behavior, it is important to identify factors that may contribute to suboptimal compliance and persistence with osteoporosis medications. OBJECTIVE: The purpose of this descriptive analysis was to identify concurrent prescription medication use (number and type) among women receiving daily or weekly oral bisphosphonate therapy. METHODS: Patient prescription data were collected from November 1999 to June 2004 from a US patient claims database accessed through Wolters Kluwer Health (formerly NDC Health), which represents >65 million patients annually. Women aged >or=50 years who were receiving daily or weekly oral bisphosphonate medication during the study months were included. Concomitant medications were defined based on >or=14 days of prescription supply in the same month as bisphosphonate therapy. Data were examined to determine the frequency with which certain drugs and drug classes were prescribed concomitantly with bisphosphonates. Each study month was treated independently to assess concomitant medication use. RESULTS: Over the study period, the number of female bisphosphonate recipients in the database increased from 78,909 to 250,286. At the end of the study, 16.2%, 12.2%, 8.7%, and 19.1% of bisphosphonate recipients were prescribed 3, 4, 5, or >or=6 concomitant medications, respectively. The most commonly prescribed concomitant drug classes were cholesterol reducers, diuretics, beta-blockers, calcium channel blockers, synthetic thyroid hormones, angiotensin-converting enzyme inhibitors, systemic analgesics/anti-inflammatory drugs, and antispasmodics/antisecretory drugs. From July 2001 until the end of the study, the number of concomitant medications was higher for women receiving daily bisphosphonates than for those receiving weekly bisphosphonates, 4.16 versus 3.77 as of June 2004. In addition, the mean number of concomitant medications prescribed increased with age: in the aged 50 to 64 years cohort, the aged 65 to 74 years cohort, and the aged >or=75 years cohort, the mean number was 3.09, 3.62, and 3.97, respectively, as of June 2004. CONCLUSION: This analysis suggests that women prescribed bisphosphonates have a high medication burden, with the majority of patients (56%) taking >or=3 concomitant prescription medications.

Postmenopausal osteoporosis: etiology, current diagnostic strategies, and nonprescription interventions.

OBJECTIVE: To describe the etiology, diagnosis, and nonprescription interventions for the prevention and treatment of postmenopausal osteoporosis. BACKGROUND: Osteoporosis affects more than 20 million individuals in North America and is responsible for more than 1.5 million fractures in the United States. About 50% of white women in the United States will have an osteoporotic fracture during their lifetime. SUMMARY: Postmenopausal osteoporosis is the result of estrogen deficiency, which results in up-regulation of several cytokines and excessive bone resorption. Various bone mineral density (BMD) testing methods are available, but the World Health Organization based the diagnosis of postmenopausal osteoporosis on the presence of a BMD T-score that is 2.5 standard deviations or greater below the mean for young women as assessed by dual-energy X-ray absorptiometry (DXA) at the hip, spine, and mid-radius. Ensuring adequate calcium and vitamin D intake is the cornerstone of any regimen aimed at preventing or treating postmenopausal osteoporosis. Other nonpharmacologic measures address modifiable risk factors for the disease and include exercise, smoking cessation, reducing consumption of caffeine and alcohol, and avoiding medications known to decrease bone mass. CONCLUSIONS: Postmenopausal osteoporosis is the result of estrogen deficiency and excessive bone resorption. Ensuring intake combined with lifestyle changes to address modifiable risk factors for the disease may help in the prevention and treatment of this condition.

Male osteoporosis: new trends in diagnosis and therapy.

Osteoporosis is a common condition in men affecting approximately 2 million males in the US. Compared with women, osteoporosis develops later in life and the incidence of osteoporosis-related fractures is lower in men. The morbidity and mortality associated with osteoporotic fractures are much greater in men compared with women, and secondary causes of osteoporosis are more frequently (in approximately 50% of cases) identified in men compared with women with osteoporosis. Excessive alcohol consumption, glucocorticoid excess and hypogonadism are the most commonly identified causes. Primary osteoporosis in men has been linked to changes in sex steroid secretion, the growth hormone-insulin-like growth factor-1 (GH-IGF-1) axis and the vitamin D-parathyroid hormone (PTH) 25-hydroxyvitamin D [25(OH)D]-PTH system. Diagnosing osteoporosis in men is complicated by an ongoing debate on whether to use sex-specific reference values for bone mineral density (BMD) or female reference values. The International Society for Clinical Densitometry recommended using a T score of -2.5 or less of male reference values to diagnose osteoporosis in men who are > or =65 years of age. However, this definition is yet to be validated in terms of fracture incidence and prevalence. Ensuring adequate calcium and vitamin D intake is the cornerstone of any regimen aimed at preventing or treating osteoporosis in men. Bisphosphonates are currently the therapy of choice for treatment of male osteoporosis. A short course of parathyroid hormone (1-34) [teriparatide] may be indicated for men with very low BMD or in those in whom bisphosphonate therapy is unsuccessful. The use of testosterone-replacement therapy for the prevention and treatment of male osteoporosis remains controversial but likely to benefit osteoporotic men with evident hypogonadism.

Predictors of do not resuscitate orders in the nursing home.

BACKGROUND: The outcome of cardiopulmonary resuscitation of residents of long-term care facilities is poor. However, only about one half of residents of long term care facilities have a do not resuscitate (DNR) order. The remainder usually have resuscitation by order or by default policy. Understanding predictors of DNR may help clinicians address end-of-life issues with the older long-term care population. OBJECTIVES: To determine (1) the prevalence of DNR orders, and (2) predictors of DNR orders in older institutionalized individuals in a large community teaching nursing home. METHODS: A cross-sectional chart review study of 177 consecutively located older patients from an 899-bed academic long-term care facility. RESULTS: The prevalence of a DNR order was 40%. The frequency of ordering DNR was greater in subjects who were 85 years or older compared with subjects who were younger than 85 years (57% vs. 30%, P < .05). Ordering DNR was associated significantly with race (49% of whites compared with 13% African Americans, P < .05) but not with sex. Subjects with a DNR order were more likely to have been diagnosed with depression (52% vs. 35%, P < .05) but not dementia, and overall had greater number of medical conditions (5.9 +/- 2 vs. 5.1 +/- 2, P < .05) compared with subjects without DNR orders. The frequency of DNR orders did not significantly differ between subjects who were able to ambulate (with or without assistance) compared with subjects who were wheelchair or bed bound. Using logistic regression analysis, only age (with a B of -1.04 and P of .017) and race (with a B of 1.4 and a P of .01) were independent predictors of DNR status. CONCLUSION: Fewer than half of this sample of long-term care residents had a DNR order. Among seven factors studied, only age and race were independent predictors of DNR status in the nursing home.

Sarcopenia and aging.

Sarcopenia refers to the gradual decline in muscle mass and quality noted with advancing age. There is growing evidence linking sarcopenia to functional disability, falls, decreased bone density, glucose intolerance, and decreased heat and cold tolerance in older adults. Factors implicated in the etiology of sarcopenia include decreased physical activity, malnutrition, increased cytokine activity, oxidative stress, and abnormalities in growth hormone and sex steroid axes. At present, progressive resistance training is the best intervention shown to slow down or reverse this condition. Preliminary studies show that the utilization of several trophic factors, notably testosterone and DHEA, may have a salutary effect on muscle mass and/or strength in older adults. More research is needed, however, before drawing definite conclusion as to the clinical utility of these substances in the management of sarcopenia.

Time to ambulation after hip fracture surgery: relation to hospitalization outcomes.

OBJECTIVE: To test the hypothesis: Time to ambulation (walking) after hip fracture surgery impacts the frequency of postoperative complications and length of hospital stay. METHODS: A retrospective observational study of a cohort of all patients admitted to a university teaching hospital with a principal International Classification of Diseases-9 diagnosis of a hip fracture during 3 calendar years. RESULTS: A total of 131 participants were identified (68% were aged 65 years or older). Overall, the mean time to writing an order to ambulate a patient after a hip fracture surgery was 2 +/- 1.5 days. Time to ambulation after hip fracture surgery was significantly less in patients cared for on orthopedic surgery service compared to general surgery service (1.8 +/- 1 vs 2.5 +/- 2, p <.05) or general internal medicine service (2.5 +/- 1.5, p <.05). It did not relate, however, to patient's age, sex, or race, or to patient's functional status prior to admission, fracture site (femoral neck, intertrochanteric, or subtrochanteric), whether a femoral neck fracture is displaced or not, type of anesthesia (spinal/epidural vs general), type of surgery (open reduction and internal fixation vs hemiarthroplasty), degree of preoperative risk, number of medical conditions, or to obtaining physical therapy and/or medical consultation. Time to ambulation after surgery was an independent predictor for the development of pneumonia (1.5 OR [odds ratio]/day, p <.001), new onset delirium (1.7 OR/day, p <.001), and to prolonged length of hospital stay (B [slope coefficient] = 1.36, p <.0001) but not to the development of pressure ulcers, deep venous thrombosis, or urinary tract infection. CONCLUSIONS: Delayed ambulation after hip fracture surgery is related to the development of new onset delirium and pneumonia postoperatively as well as to increased length of hospital stay. Early ambulation after hip fracture surgery should be encouraged.

The underuse of therapy in the secondary prevention of hip fractures.

There is strong evidence to indicate that individuals who sustain a hip fracture are at a greater risk of developing another. The management of such patients should include efforts to prevent future fractures, including prescribing medications that have been shown to lower hip fracture risk. Such therapies that are currently available include calcium and vitamin D supplementation, alendronic acid and risedronic acid. In addition, there is epidemiological evidence to indicate that estrogen may also decrease the risk of hip fracture. Parathyroid hormone is another agent that has shown promise in this regard and is likely to be available for clinical use in the near future. However, the rates of utilisation of these therapies among patients with hip fractures are low. It is important to emphasise that secondary prevention of hip fractures should be an integral part of the management of individuals who sustain hip fractures.

Role of hormones in the pathogenesis and management of sarcopenia.

There is growing evidence to indicate that age-related declines in growth hormone (GH), insulin-like growth factor (IGF)-1, and androgen and estrogen production play a role in the pathogenesis of sarcopenia (an age-related decline in muscle mass and quality). Although GH supplementation has been reported to increase lean body mass in elderly individuals, the high incidence of adverse effects combined with a very high cost has limited the applicability of this form of therapy. The assessment of an alternative approach to enhance the GH/IGF-1 axis in the elderly by using GH-releasing hormone and other secretagogues is currently under way and is showing some promise. Testosterone replacement therapy may increase muscle mass and strength and decrease body fat in hypogonadal elderly men. Long-term randomised, controlled trials are needed, however, to better define the risk-benefit ratio of this form of therapy before it can be recommended. Available data are currently insufficient to decide what role estrogen replacement therapy may play in the management of sarcopenia. Therefore, although the evidence linking age-related hormonal changes to the development of sarcopenia is rapidly growing, it is still too early to determine the clinical utility of hormonal supplementation in the management of sarcopenia.

Sex and the nursing home.

Despite the known benefits of continued sexual activity on physical, mental, and emotional health, the nursing home resident continues to be sexually invisible. There are so few opportunities where the quality of life can be enhanced so greatly by so basic interventions. Sexuality in the nursing home is one of them. Failure of society to come to grips with the sexual needs of the elderly essentially robs them of a fundamental element of self-worth.

Underutilization of calcium and vitamin D supplements in an academic long-term care facility.

BACKGROUND: Good scientific evidence indicates that calcium and vitamin D supplementation decrease the incidence of osteoporosis-related fractures among institutionalized elderly. OBJECTIVE: The objective was to study the frequency of prescribing calcium and vitamin D supplements in elderly institutionalized individuals in a large community teaching nursing home. METHODS: A cross-sectional chart review study of 177 consecutively located elderly residents from an 899-bed academic long-term care facility. RESULTS: Calcium and vitamin D supplements were prescribed in only 12% and 9% of subjects, respectively. Among subjects with the diagnosis of osteoporosis (n = 12), 66% were prescribed calcium and 58% were prescribed vitamin D supplements. Among subjects with hip fractures (n = 8), only 25% were prescribed calcium with a similar percentage prescribed vitamin D supplements. Female residents were more likely than male residents to receive calcium (P <0.05) and vitamin D supplements (P = 0.08). CONCLUSION: There is a major need to increase the utilization of calcium and vitamin D supplementation among institutionalized elderly to decrease the risk of osteoporotic fractures, including hip fractures.

Osteoporosis for the home care physician. Part 1: etiology and current diagnostic strategies.

Osteoporosis affects over 20 million individuals in North America and is responsible for over 1.5 million fractures in the US. Although most cases of osteoporosis are primary, in 20% of older women and 40% of older men presenting with vertebral fractures, a secondary cause can be identified. The WHO based the diagnosis of postmenopausal osteoporosis on the presence of BMD T-score that is 2.5 standard deviations or greater below the mean for young women. The International Society of Clinical Densitometry defined male osteoporosis as BMD T-score of 2.5 or greater below the mean for young men. BMD assessment at the hip and spine by DXA is the standard procedure to assess bone density. Laboratory testing in patients with low BMD is performed to exclude other conditions that could cause low BMD such as multiple myeloma, endocrinopathies and osteomalacia. Bone turnover marker levels currently do not predict bone mass or fracture risk and are only weakly associated with changes in bone mass. Subsequently, they are of limited use in the clinical evaluation of bone density changes.

Sexuality in the nursing home, part 1: attitudes and barriers to sexual expression.

Sexuality is a basic human need that begins at birth and continues throughout life. The sexual needs of the elderly are similar to those of the young, but with variations in frequency, intensity, and mode of expression. Regardless of age, every individual has a need for love, intimacy, and companionship. Unfortunately, however, stereotypical thinking, ignorance, and prejudice dominate Western society's view on sexuality in the elderly. In a youth-oriented culture, sexuality is attributed to the young, healthy, and beautiful, and the myth that the elderly are asexual beings predominates. Consequently, the sexual needs of the elderly are frequently overlooked and ignored. Nowhere is this more emphatic than in the nursing home setting. This article explores barriers to sexual expression in the nursing home setting and discusses strategies to overcome them.

Sexuality in the nursing home, part 2: managing abnormal behavior--legal and ethical issues.

Everyone, regardless of age, needs love, touch, companionship, and intimacy. The 1.6 million elderly in the 20,000 U.S. nursing homes are not an exception. The literature indicates that nursing home residents continue to have an interest in sexual activity regardless of age. Sexuality, however, is frequently overlooked by physicians and staff working with nursing home residents. Many staff members have only a vague understanding of the sexual needs of the elderly. This results in a perception of residents' sexual interests as behavioral problems rather than expressions of need for love and intimacy. Inappropriate sexual behaviors in the nursing home can create an intense burden for nursing home staff. This article discusses ways to dealing with inappropriate sexual behaviors in long-term care settings and the ethical issues involved.

Sexuality in the nursing home, part 2: Managing abnormal behavior-legal and ethical issues.

Everyone, regardless of age, needs love, touch, companionship, and intimacy. The 1.6 million elderly in the 20,000 U.S. nursing homes are not an exception. The literature indicates that nursing home residents continue to have an interest in sexual activity regardless of age. Sexuality, however, is frequently overlooked by physicians and staff working with nursing home residents. Many staff members have only a vague understanding of the sexual needs of the elderly. This results in a perception of residents' sexual interests as behavioral problems rather than expressions of need for love and intimacy. Inappropriate sexual behaviors in the nursing home can create an intense burden for nursing home staff. This article discusses ways to dealing with inappropriate sexual behaviors in long-term care settings and the ethical issues involved.

Sexuality in the nursing home, part 1: attitudes and barriers to sexual expression.

Sexuality is a basic human need that begins at birth and continues throughout life. The sexual needs of the elderly are similar to those of the young, but with variations in frequency, intensity, and mode of expression. Regardless of age, every individual has a need for love, intimacy, and companionship. Unfortunately, however, stereotypical thinking, ignorance, and prejudice dominate Western society's view on sexuality in the elderly. In a youth-oriented culture, sexuality is attributed to the young, healthy, and beautiful, and the myth that the elderly are asexual beings predominates. Consequently, the sexual needs of the elderly are frequently overlooked and ignored. Nowhere is this more emphatic than in the nursing home setting. This article explores barriers to sexual expression in the nursing home setting and discusses strategies to overcome them.