Adverse drug reaction-related hospitalizations of nursing facility patients: a 4-year study.

BACKGROUND: The purpose of this study was to document adverse drug reaction (ADR)-related hospitalizations from a nursing facility population. METHODS: This 4-year prospective observational study used monthly repeated measures of 332 residents present for 30 or more days. The review included admission and monthly drug regimen review for each resident. Each probable ADR was sent with monthly reports to attending physicians and charge nurses. RESULTS: There were 64 ADR-associated hospitalizations in 52 of the 332 residents (15.7%). The most common events were for nonsteroidal anti-inflammatory drugs (NSAIDs) (30), psychotropic-related fall with fracture (14), digoxin toxicity (5), and insulin hypoglycemia (4). Five patients had recurrence of the hospitalization for the same problem. A significant factor noted between ADR hospitalized and non-ADR residents was the number of medications per patient (7.9 +/- 2.6 vs 3.3 +/- 1.3) for the same number of problems. CONCLUSIONS: Adverse drug reaction-related hospitalizations may affect as many as one of every seven nursing home residents and appear to be related to polypharmacy as well as inattention to patient history of contraindications and previous ADRs.

Consultant pharmacist drug therapy recommendations from monthly drug regimen reviews in a geriatric nursing facility: a two-year study and cost analysis.

PURPOSE: To analyze drug therapy recommendations acceptance or rejection costs in a nursing facility practice over 2 years. METHODS: Admission patient assessment, problem list and monthly problem-oriented drug regimen review (DRR) and assessment , with written report and mandated response by attending physician and follow-up on subsequent months DRR. Descriptive statistics of patient demographics and recommendation acceptance and types. Cost calculation of consequences of acceptance or rejection. SUMMARY OF RESULTS: In 204 predominantly female patients (age 83.7 +/- 7.8 years), with 4.5 +/- 1.3 active problems per patient, 4,008 monthly drug regimen reviews resulted in 374 recommendations (9.3% of reviews). In decreasing rank order, recommendations were for adverse drug reaction and interaction detection and resolution (156), discontinue medications (74), buspirone conversion from other psychotropic(s) (60), change medications (33), needed nutritional or drug therapy (26), change dose, dosing interval, dosage form, or administration technique (25). The cost savings from recommendation acceptance was $223,218; rejection $224,593. CONCLUSION: Geriatric long-term care patients appear to have numerous drug-related problems (DRPs) requiring unsolicited consultations, especially adverse drug reactions. Acceptance of consultant pharmacist recommendations may influence cost of overall care.

Radiometric Measurement Comparison Using the Ocean Color Temperature Scanner (OCTS) Visible and Near Infrared Integrating Sphere.

As a part of the pre-flight calibration and validation activities for the Ocean Color and Temperature Scanner (OCTS) and the Sea-viewing Wide Field-of-view Sensor (SeaWiFS) ocean color satellite instruments, a radiometric measurement comparison was held in February 1995 at the NEC Corporation in Yokohama, Japan. Researchers from the National Institute of Standards and Technology (NIST), the National Aeronautics and Space Administration/Goddard Space Flight Center (NASA/GSFC), the University of Arizona Optical Sciences Center (UA), and the National Research Laboratory of Metrology (NRLM) in Tsukuba, Japan used their portable radiometers to measure the spectral radiance of the OCTS visible and near-infrared integrating sphere at four radiance levels. These four levels corresponded to the configuration of the OCTS integrating sphere when the calibration coefficients for five of the eight spectral channels, or bands, of the OCTS instrument were determined. The measurements of the four radiometers differed by -2.7 % to 3.9 % when compared to the NEC calibration of the sphere and the overall agreement was within the combined measurement uncertainties. A comparison of the measurements from the participating radiometers also resulted in agreement within the combined measurement uncertainties. These results are encouraging and demonstrate the utility of comparisons using laboratory calibration integrating sphere sources. Other comparisons will focus on instruments that are scheduled for spacecraft in the NASA study of climate change, the Earth Observing System (EOS).

Probable adverse drug reactions in a rural geriatric nursing home population: a four-year study.

OBJECTIVE: To quantitate probable adverse drug reactions (ADRs) in a geriatric nursing homes population. DESIGN: A repeated measures prospective study. SETTING: Two nursing home populations in rural Georgia. PATIENTS: All 332 residents present for 30 or more days over a 4-year period. MEASUREMENT: Admission and monthly drug regimen review for each resident, Naranjo algorithm assessment of each ADR, with monthly reports to attending physicians and follow-up within the next month. RESULTS: There were 444 probable ADRs in 217 of 332 residents (67.4%) during this period. The 217 residents had a mean 1.9 +/- 1.3 probable adverse drug reactions (range, 1-9). The ADR group differed statistically from the rest of the population only in the number of drugs per patient (7.8 +/- 2.6 vs 3.3 +/- 1.3), which was almost twice the number of active problems present in both the ADR (4.0 +/- 0.9) and non-ADR populations (3.8 +/- 1.4). The organ systems most commonly involved in the 444 ADRs observed were cardiovascular (188), central nervous system (129), gastrointestinal (82), endocrine (41), immune (17), hematologic (7), pulmonary (6), and renal (5). The drugs most commonly implicated in ADRs were, in decreasing order, diuretics, antipsychotics, anxiolytics, potassium supplements, digoxin, NSAIDs, insulin, theophylline, H2-receptor antagonists, antiinfectives, anticonvulsants, and thyroid supplements. There were 39 multiple drug ADRs in 34 patients. In decreasing order the drug classes in multiple ADRs were CNS depressants, antihypertensives, potassium-altering therapy, and NSAIDs. Numerous patients had repetitions of the same ADR, especially with antipsychotics, NSAIDs, and insulin. CONCLUSIONS: ADRs are a common occurrence in a geriatric nursing home population, and may be related to inadequate attention to the patients history as well as to unrealistic therapeutic endpoints.

Polypharmacy in the aged. Practical solutions.

Elderly patients use more medications than younger patients and the trend of increasing drug use continues through 80 years of age. Studies conducted in a variety of settings have shown that patients over 65 years of age use an average of 2 to 6 prescribed medications and 1 to 3.4 non-prescribed medications. Success of pharmaceutical and medical research has resulted in an abundance of effective drugs to treat acute and chronic conditions. Most research resulting in the development and marketing of these medications has been directed at proving the efficacy and safety of single drug products. Little research has been directed to determine the safety and efficacy of combining multiple medications to treat concurrent conditions in a single patient. It is known that the use of multiple medications increases the risks of adverse drug reactions, drug-drug interactions, and makes compliance with medication regimens more difficult. Numerous studies have been conducted to better understand factors that are associated with increased drug use in elderly people. Studies also have been conducted to identify interventions that can improve drug treatment for the elderly, and reduce polypharmacy. Multiple drug use is common in older people, and may give rise to drug related problems. Methods to reduce the risks of polypharmacy include patient education, physician education, such as education and feedback systems, and regulatory intervention. Continual drug and disease monitoring is essential.

Clinical outcomes research in pharmacy practice.

Clinical outcomes research in pharmacy practice is essential to the sustained growth and maturation of the profession in the evolving health care system. Anecdotal evidence and ongoing studies have begun to identify and prioritize drug-related problems, methods to anticipate and solve these problems, and obstacles that will have to be overcome to maximize the place of pharmacy in health care. The health care system will change, and an increased level of pharmacist responsibility for paid pharmaceutical care should result in improved clinical outcomes. Clinical outcomes research is vital to demonstrate the effectiveness of pharmacists, document the cost benefits of pharmaceutical care, and determine a national standard of pharmaceutical care.

Use of the smaller pediatric transesophageal echocardiographic probe in adults.

Transesophageal echocardiography in the adult uses a relatively large diameter probe, which may be poorly tolerated by certain patients. The use of a smaller probe designed for pediatric patients was studied in 50 adults (21 males and 29 females), and concomitant transesophageal echocardiography studies were performed using the regular adult-sized probe in 28 of these patients. The smaller pediatric transesophageal echocardiography probe was easier to pass, better tolerated, caused a smaller heart rate increase (13 +/- 3 vs 20 +/- 4 beats/min, P = 0.0029), and required no sedation in more patients than the adult transducer. The resolution of the two-dimensional and color Doppler images in the mid and near fields of the smaller probe were comparable to the larger probe, as were the maximal area of mitral regurgitation and the ratio of the maximal proximal width of the aortic insufficiency jet to the left ventricular outflow tract diameter in patients with these lesions. However, the image resolution was noticeably inferior to the adult probe in the far field, such as when imaging the distal left ventricle or imaging structures transgastrically. Therefore, the smaller probe designed for pediatric use allows satisfactory near- and mid-field two-dimensional and color Doppler flow imaging in comparison to the adult probe and would be expected to be beneficial in adult patients in whom superior quality imaging of the far-field is not required clinically, those who tolerate poorly the adult probe, relatively high-risk patients in whom no sedation is desirable, and in those patients in whom passage of the larger probe is unsuccessful.

Color Doppler assessment of high flow velocities using a new technology: in vitro and clinical studies.

This study validates the accuracy of the newly-developed Quasar technique in the assessment of high flow velocities using color Doppler flow mapping.

Reviewing geriatric concerns with commonly used drugs.

The most important special consideration for drug use in the last years of life is that the medications prescribed do what is intended and do not contribute to morbidity or premature mortality. Key factors in appropriate use are reviewed for analgesics, anti-inflammatories, corticosteroids, thyroid drugs, anti-diabetic agents, digoxin, newer antiarrhythmics, beta-blockers, diuretics and potassium supplements, sympatholytic and vasodilatory antihypertensives, warfarin and heparin, anxiolytics, neuroleptics, anticonvulsants, antidepressants, antimicrobials, laxatives, gastrointestinal and bronchodilatory agents, and nutritional supplements and vitamins.

Erythromycin-induced digoxin toxicity.

The potential interaction between certain antibiotics and digoxin has been discussed in the literature; however, few cases of actual erythromycin-induced digoxin toxicity have been reported. We present a case in which an 86-year-old woman who was taking digoxin 0.25 mg/d developed probably digoxin toxicity after the administration of erythromycin for the treatment of otitis media and streptococcal pharyngitis. Her digoxin concentration increased from a trough of 1.9 to 5.1 nmol/L six days after the erythromycin was started. Digoxin was discontinued and restarted approximately six weeks later when the patient's atrial fibrillation and congestive heart failure recurred. Her digoxin dose at this time was 0.125 mg/d and resulted in steady-state concentrations of 1.2, 1.4, and 1.2 nmol/L over the next year. Erythromycin inhibition of Eubacterium lentum, which converts digoxin into digoxin-reduction products in the gut, is the proposed mechanism of this interaction.