Multidisciplinary Approach to Deprescribing Sedative-Hypnotic Medications in Geriatric Primary Care.

INTRODUCTION/OBJECTIVES: Due to the risks associated with sedative hypnotic medications in older adults, our study evaluated the impact of a multidisciplinary approach to deprescribing in geriatric primary care clinics. METHODS: The study was a retrospective review of older adults at 2 academic, geriatric primary care clinics who were prescribed sedative-hypnotic medications. Patients were mailed an education packet of information that included working with the clinical pharmacy team, behavioral health team, or both in order to deprescribe their sedative-hypnotic medication. The study assessed the rate of discontinuation of sedative-hypnotic medications between the different intervention groups. RESULTS: The study included 93 older adults with a mean age of 81.3 years and 39.8% discontinuation rate of their medication. The number of falls decreased in patients who discontinued use compared to when previously using a sedative hypnotic medication. CONCLUSION: Patients are more likely to discontinue their sedative hypnotic medication with a multidisciplinary approach, specifically with primary care provider support.

Disparities in Video and Telephone Visits Among Older Adults During the COVID-19 Pandemic: Cross-Sectional Analysis.

BACKGROUND: Telephone and video telemedicine appointments have been a crucial service delivery method during the COVID-19 pandemic for maintaining access to health care without increasing the risk of exposure. Although studies conducted prior to the pandemic have suggested that telemedicine is an acceptable format for older adults, there is a paucity of data on the practical implementation of telemedicine visits. Due to prior lack of reimbursement for telemedicine visits involving nonrural patients, no studies have compared telephone visits to video visits in geriatric primary care. OBJECTIVE: This study aimed to determine (1) whether video visits had longer durations, more visit diagnoses, and more advance care planning discussions than telephone visits during the rapid implementation of telemedicine in the COVID-19 pandemic, and (2) whether disparities in visit type existed based on patient characteristics. METHODS: We conducted a retrospective, cross-sectional analysis of patients seen at two geriatric clinics from April 23 to May 22, 2020. Approximately 25% of patients who had telephone and video appointments during this time underwent chart review. We analyzed patient characteristics, visit characteristics, duration of visits, number of visit diagnoses, and the presence of advance care planning discussion in clinical documentation. RESULTS: Of the 190 appointments reviewed, 47.4% (n=90) were video visits. Compared to telephone appointments, videoconferencing was, on average, 7 minutes longer (mean 37.3 minutes, SD 10 minutes; P<.001) and had, on average, 1.2 more visit diagnoses (mean 5.7, SD 3; P=.001). Video and telephone visits had similar rates of advance care planning. Furthermore, hearing, vision, and cognitive impairment did not result in different rates of video or telephone appointments. Non-White patients, patients who needed interpreter services, and patients who received Medicaid were less likely to have video visits than White patients, patients who did not need an interpreter, and patients who did not receive Medicaid, respectively (P=.003, P=.01, P<.001, respectively). CONCLUSIONS: Although clinicians spent more time on video visits than telephone visits, more than half of this study's older patients did not use video visits, especially if they were from racial or ethnic minority backgrounds or Medicaid beneficiaries. This potential health care disparity merits greater attention.

Pharmacist-Led Transition of Care Pilot Targeting Older People After Emergency Department Discharge.

OBJECTIVE: To evaluate the impact of a pharmacist-led transitional care intervention targeting high-risk older people after an emergency department (ED) visit.
DESIGN: Retrospective cohort study of older people with ED visits prior to and during a pharmacist-led intervention.
SETTING: Patients receiving primary care from the University of Colorado Health Seniors Clinic.
PARTICIPANTS: The intervention cohort comprised 170 patients with an ED visit between August 18, 2018, and February 19, 2019, and the historical cohort included 166 patients with an ED visit between August 18, 2017, and February 19, 2018. All included patients either had a historical diagnosis of heart failure or chronic obstructive pulmonary disease, or they had an additional ED visit in the previous six months.
INTERVENTIONS: The pilot intervention involved postED discharge telephonic outreach and assessment by a clinical pharmacist, with triaging to other staff if necessary.
MAIN OUTCOME MEASURE: The primary outcome was the proportion of patients with at least one repeat ED visit, hospitalization, or death within 30 days of ED discharge. Outcome rates were also assessed at 90 days postdischarge.
RESULTS: The primary outcome occurred in 21% of the historical cohort and 25% of the intervention cohort (adjusted P-value = 0.48). The incidence of the composite outcome within 90 days of ED discharge was 43% in the historical group compared with 38% in the intervention group (adjusted P-value = 0.29).
CONCLUSION: A pharmacist-led telephonic intervention pilot targeting older people did not appear to have a significant effect on the composite of repeat ED visit, hospitalization, or death within 30 or 90 days of ED discharge. A limited sample size may hinder the ability to make definitive conclusions based on these findings.

Characteristics and Patterns of Marijuana Use in Community-Dwelling Older Adults.

OBJECTIVES: To understand patterns of marijuana use in community-dwelling older adults in Colorado. DESIGN: Anonymous survey. SETTING: Two academic geriatric primary care clinics. PARTICIPANTS: English-speaking individuals. MEASUREMENTS: We assessed self-reported characteristics and patterns of marijuana use and effect on targeted symptoms. Survey analysis focused on current users, defined as individuals who had used marijuana in the past 3 years. RESULTS: Three hundred forty-five individuals completed the survey (55% response rate); 113 (32%) had used marijuana in the past, of whom 55 (16%) had used since legalization. More than half of current users were aged 75 and older, and one-quarter were aged 85 and older. Most current users were white women. Of current users, 44% used marijuana products at least weekly for common conditions including chronic pain, depression, anxiety, and insomnia, and most found marijuana helpful for these conditions. Most respondents reported obtaining marijuana recreationally (67%) without a prescription. Nine respondents reported negative side effects attributable to marijuana use. CONCLUSION: To our knowledge, this is the first study to characterize marijuana use of older adults in a state in which it is legal for medical and recreational use. Marijuana was used for several common geriatric conditions, and respondents reported few side effects. The small number of survey respondents, the lack of generalizability in states where marijuana sales are illegal, and participation bias were the main study limitations. Further research is needed to better understand useful or harmful effects in this population. J Am Geriatr Soc 66:2167-2171, 2018.

Development and economic evaluation of a pharmacist-provided chronic care management service in an ambulatory care geriatrics clinic.

PURPOSE: The implementation and delivery of a pharmacist-led chronic care management (CCM) service in a geriatric primary care clinic are described. METHODS: A CCM service was provided March 1 through December 31, 2016, at the University of Colorado Hospital Seniors Clinic ("Seniors Clinic"). The electronic health record (EHR) team for the University of Colorado Health system developed a patient registry through EPIC Healthy Planet (Epic Systems Corp., Verona, WI) to identify patients at the Seniors Clinic eligible for CCM services. The EHR team constructed a note type and documentation template within the EHR to ensure documentation of all necessary components for billing and to allow individual clinical staff to document the time spent providing CCM care. RESULTS: Overall, 36 elderly patients enrolled in the pharmacist-provided CCM service over the 10 months. Clinical pharmacists spent a total of 156-849 minutes per month providing CCM services, with a mean outreach time of 45.4 minutes per patient. The clinical pharmacists submitted 95 claims, and all but 5 were paid. The total amount reimbursed from the health plans during the 10 months was $2,775.02. CONCLUSION: Medicare patients were successfully enrolled in a CCM service in a geriatrics primary care clinic led by clinical pharmacists and medical providers. The CCM services were more time-consuming than the allotted 20 minutes per patient per month with the CCM Current Procedural Terminology code used during this study.

Pulmonary and hepatic toxicity due to nitrofurantoin and fluconazole treatment.

OBJECTIVE: To reemphasize potential risks associated with chronic nitrofurantoin use and to report a case of combined pulmonary and hepatic toxicity precipitated from acute use of fluconazole concomitantly with chronic nitrofurantoin. CASE SUMMARY: A 73-year-old white man taking nitrofurantoin 50 mg/day for 5 years developed combined hepatic and pulmonary toxicity after taking fluconazole acutely for onychomycosis. Two months after starting fluconazole, the patient's hepatic enzymes showed elevation 5 times the upper limits of normal. In addition, the patient reported fatigue, dyspnea on exertion, pleuritic pain, burning trachea pain, and a cough. Chest X-rays showed bilateral pulmonary disease consistent with nitrofurantoin toxicity. Both drugs were determined to be the cause of the patient's pulmonary and hepatic toxicity, so they were discontinued. Pulmonary function tests measured after discontinuation were abnormal and also consistent with nitrofurantoin toxicity. The patient's hepatic and pulmonary toxicity resolved upon discontinuation of both drugs and use of inhaled corticosteroids. DISCUSSION: Changes in hepatic enzyme measurement, pulmonary function measurements, and chest X-rays indicate that our patient developed hepatic and pulmonary toxicity due to his drug therapy. An objective causality assessment revealed that these adverse events were probably due to fluconazole given with nitrofurantoin. Either drug may have caused the hepatic toxicity. However, it is possible that pharmacokinetic changes induced by an interaction with fluconazole precipitated the nitrofurantoin-induced pulmonary toxicity. CONCLUSIONS: Our patient developed pulmonary and hepatic toxicity after starting fluconazole in combination with chronic nitrofurantoin. A potential drug interaction of unknown mechanism may have been the cause of the toxicities.

Clinical decisions regarding HbA1c results in primary care: a report from CaReNet and HPRN.

OBJECTIVE: To describe decisions made by primary care providers on elevated HbA(1c) results and their reasons for not intensifying therapy. RESEARCH DESIGN AND METHODS: In this cross-sectional study, a provider survey was administered in two practice-based research networks when HbA(1c) results were reviewed on all nonpregnant patients >18 years old with type 2 diabetes. Univariate and Mantel-Hantel analyses assessed associations between patient characteristics and clinical decisions. RESULTS: A total of 483 surveys were completed by at least 88 providers at 19 clinics. Most patients were female (62.5%), mean age was 60 years, and 28.6% were Hispanic. The overall action rate on HbA(1c) results >/=7% (n = 294) was 70.7%. Patients who were black or had Medicare without medication insurance had lower rates of action on HbA(1c) >/=7 and >/=8%, respectively (P < 0.05). The most common reasons providers reported for inaction were "patient improving/doing well," "competing demands," and "hypoglycemic risk." CONCLUSIONS: Primary care providers generally adhere to national glycemic control guidelines, although there may be disparities in black patients and patients without medication insurance coverage. A variety of reasons were given when control was not intensified.

Medications for the Treatment of Sleep Disorders: An Overview.

Sleep disorders can be divided into those producing insomnia, those causing daytime sleepiness, and those disrupting sleep. Transient insomnia is extremely common, afflicting up to 80% of the population. Chronic insomnia affects 15% of the population. Benzodiazepines are frequently used to treat insomnia; however, there may be a withdrawal syndrome with rapid eye movement (REM) rebound. Two newer benzodiazepine-like agents, zolpidem and zaleplon, have fewer side effects, yet good efficacy. Other agents for insomnia include sedating antidepressants and over-the-counter sleep products (sedating antihistamines). Nonpharmacologic behavioral methods may also have therapeutic benefit. An understanding of the electrophysiologic and neurochemical correlates of the stages of sleep is useful in defining and understanding sleep disorders. Excessive daytime sleepiness is often associated with obstructive sleep apnea or depression. Medications, including amphetamines, may be used to induce daytime alertness. Parasomnias include disorders of arousal and of REM sleep. Chronic medical illnesses can become symptomatic during specific sleep stages. Many medications affect sleep stages and can thus cause sleep disorders or exacerbate the effect of chronic illnesses on sleep. Conversely, medications may be used therapeutically for specific sleep disorders. For example, restless legs syndrome and periodic limb movement disorder may be treated with dopamine agonists. An understanding of the disorders of sleep and the effects of medications is required for the appropriate use of medications affecting sleep.