Evaluating the Effects of a Medication Adherence Packaging Program on Outcomes in Older People.

Objective To determine the impact of an adherence packaging and medication synchronization program on hospital visits for older people living independently in the community. Design A retrospective pre-post study that evaluated patient outcomes over a 24-month period was conducted. Patient-specific socio-demographic, medical, and hospital visit-related data were collected for 12 months before and after patient enrollment in the adherence packaging program. Setting The study was conducted at Rx Partners LTC, LLC, a University of Pittsburgh Medical Center (UPMC) pharmacy in Pittsburgh, Pennsylvania. Participants Patients 65 years of age or older, of any gender, with UPMC Health Plan insurance coverage, who enrolled in the adherence packaging program between July 2019 and December 2019. Intervention Enrollment in the adherence packaging program included medication synchronization and packaging in prefilled medication sets delivered to the patient's home monthly. Monthly medication reconciliation and review by clinical pharmacists was an included value-added service. Results Of the 92 patients included in the analysis, 60 had hospital visits during their pre-enrollment period for a total of 146 visits, compared with 54 patients in the postenrollment period totaling 126 visits; however, the mean rate of hospital visits was not statistically significant (1.59 versus 1.37; P = 0.48). Pharmacists prevented 1.87 medication errors/patient in the postenrollment setting. Conclusion Enrollment in the program was associated with fewer hospital visits, though not statistically significant, and pharmacists had abundant opportunity to prevent medication errors and optimize regimens. Further evaluation is warranted in a larger cohort.

Older People and Acute Kidney Injury: A Student Perspective on Medication Changes During Hospital Admission and Transitions of Care Follow-Up.

Older people are particularly susceptible to acute kidney injury (AKI) for a variety of reasons. Because of this, medication changes during admission and transitions of care follow-up are often necessary to ensure the safety of these patients. The American Geriatrics Society's Beers Criteria provide guidance for select medications that are potentially inappropriate in the older adult population. However, other medications, particularly those for cardiovascular disease and diabetes that are not included in the kidney function-specific section of the Beers Criteria (Table 6), can sometimes be overlooked. This manuscript will provide insight to both pharmacists and student pharmacists on the importance of being vigilant for medications that may need dosage adjustment during episodes of AKI. As interns in the outpatient setting, pharmacy students can provide education to patients and their families in order to ensure these medications are being taken correctly and are properly restarted if their discontinuation was intended for only a short time.

Transitions of Care: A Student Perspective on the Value of Current Successes and Growth Opportunities in the PharmD Curriculum.

Transitions of care (TOC) is becoming an essential component of pharmacy practice, and requires problem solving that is difficult to learn in the classroom. My unique experience of interning in community and inpatient settings along with doing my own TOC research with geriatric patients has allowed me to see patients throughout the spectrum of health care, and how discrepancies arise as they move between settings. This manuscript will provide insight to pharmacy students about why TOC is a critical area for pharmacist involvement, and how we must be prepared to guide patients through these transitions as we become new practitioners.

A Geriatric Pharmacy Resident's Clinical and Educational Activities During Weekly interprofessional Team Meetings.

OBJECTIVES: To describe and gather further details about the clinical and educational activities that were documented by the geriatric pharmacist resident during both weekly interprofessional Acute Care for the Elderly (ACE) rounds as well as bedside patient counseling. DESIGN: Retrospective chart review (quality improvement project). SETTING: Inpatient geriatric service at University of Pittsburgh Medical Center (UPMC). PATIENTS: Medical learners selected one complex patient from the geriatric service for ACE rounds each week. ACTIVITIES: The geriatric pharmacist resident provided clinical information and medication education to the interprofessional team and to the patient and/or family at their bedside. Activities were documented in a newly developed template. MAIN OUTCOME MEASURES: Patient demographics, medication categories, discrepancies and dosing changes, time-in-rounds, and team members. RESULTS: De-identified data from 18 patients (72.2% female, average age 82.5 ± 9.18 years) over a 6-month period were collected and analyzed. The geriatric pharmacist resident provided most education to the team on antibiotics, antidepressants, over-thecounters (OTCs), and prescription pain medications during ACE rounds. They provided most education to the patient/family on prescription pain medications, antidepressants, OTCs, and anticoagulants. The pharmacist resident identified 38 medication discrepancies (72.2% of patients had ≥ 1 discrepancy, range 0-7) and clinically significant drug-drug interactions in 15 patients. The pharmacist resident recommended dosing changes in 12 patients and therapeutic alternatives in 11 patients. The ACE rounds lasted on average 26.6 [± 6.42] minutes and included medicine, pharmacy, social work, nurse case management, nursing, and nutrition and rehabilitative services when necessary. CONCLUSION: The results provide insight into both the clinical and educational activities of the geriatric pharmacist resident in support of interprofessional rounds.

Evaluation of Direct Oral Anticoagulant Dosing and Monitoring in Two Geriatric Outpatient Clinics.

OBJECTIVE: This study was conducted to evaluate direct oral anticoagulants (DOACs) prescribed to elderly patients in an outpatient setting, specifically evaluating if Food and Drug Administration (FDA) -approved dosing recommendations are followed.
DESIGN: This study was a retrospective quality improvement project.
SETTING: This study was conducted at geriatric hospital-based primary care clinics at the University of Pittsburgh Medical Center (UPMC), UPMC Senior Care Institute and UPMC Benedum Geriatric Center.
PATIENTS: Subjects included were 65 years of age or older; had an office visit at UPMC Senior Care Institute or UPMC Benedum Geriatric Center from September 1, 2015, to August 31, 2017; and had a DOAC on their home medications.
INTERVENTIONS: Data were obtained through retrospective chart review.
MAIN OUTCOME MEASURE: The primary objective of the study was to evaluate the appropriateness of dosing of DOACs based on FDA-labeled recommendations.
RESULTS: Of 232 patients included in analysis, 42.7% were found to have dosing inconsistent with FDAlabeled recommendations (47.3% apixaban, 35.8% rivaroxaban, and 31.6% dabigatran). No patients were prescribed edoxaban. The majority (72.7%) were dosed lower than FDA-recommended doses. Of all patients, the most frequent parameter (54.5%) for inappropriate dosing was patients meeting only 1 of 3 dose-reduction criteria when prescribed reduced-dose apixaban. Geriatrician and nongeriatrician prescribers had similar rates of prescribing DOACs with doses inconsistent with FDA-labeled recommendations (44.0% vs. 40.8%; P = 0.62).
CONCLUSION: Results suggest that DOACs used in outpatient geriatric patients are frequently dosed inconsistent with FDA-approved dosing recommendations. Further research is needed regarding clinical outcomes in older patients receiving DOACs and in those with dose adjustments inconsistent with FDA-labeled recommendations.
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Clinical Research That Matters: Designing Outcome-Based Research for Older Adults to Qualify for Systematic Reviews and Meta-Analyses.

Though older adults are more sensitive to the effects of medications than their younger counterparts, they are often excluded from manufacturer-based clinical studies. Practice-based research is a practical method to identify medication-related effects in older patients. This research also highlights the role of a pharmacist in improving care in this population. A single study rarely has strong enough evidence to change geriatric practice, unless it is a large-scale, multisite, randomized controlled trial that specifically targets older adults. It is important to design studies that may be used in systematic reviews or meta-analyses that build a stronger evidence base. Recent literature has documented a gap in advanced pharmacist training pertaining to research skills. In this paper, we hope to fill some of the educational gaps related to research in older adults. We define best practices when deciding on the type of study, inclusion and exclusion criteria, design of the intervention, how outcomes are measured, and how results are reported. Well-designed studies increase the pool of available data to further document the important role that pharmacists have in optimizing care of older patients.

2018 American Society of Consultant Pharmacists Annual Meeting & Exhibition.

Poster abstracts are evaluated based on the following criteria: significance of the problem to healthy aging or medication management; innovativeness of ideas, methods, and/or approach; methodological rigor of methods and approach; presentation of finding; implications identified for future research, practice, and/or policy; and clarity of writing. Submissions are not evaluated through the peer-reviewed process used by The Consultant Pharmacist. Industry support is indicated, where applicable. Presenting author is in italics. The poster abstract presentation is supported by the ASCP Foundation.

Perceptions of care among high-risk geriatric patients, families, and caregivers in a patient-centered medical home.

OBJECTIVE: A survey was conducted by the pharmacy team to identify improvement areas in the delivery of care in high-risk patients at a patient-centered medical home (PCMH) at the University of Pittsburgh Medical Center (UPMC). DESIGN: This survey was a quality improvement project. SETTING: The survey was conducted at UPMC Senior Care, a level-three accredited PCMH. PATIENTS: The survey was conducted in a sample of preidentified high-risk patients. INTERVENTIONS: Pharmacy performed a survey, analyzed responses for common themes, and conducted follow-up phone calls to determine the degree of goal-achievement and efficacy of educational materials provided during the initial survey. MAIN OUTCOME MEASURE: The primary goal for conducting the survey was to identify needed areas for improvement in three specific domains, namely, medication decisions, communication with providers, and goals of care. RESULTS: Medication reviews were provided for 23 of 24 surveyed, leading to medication discrepancy resolution in 58%. Almost 80% of the respondents were satisfied with the team's communication. More than 85% of respondents verbalized the goals they wanted to achieve in three months. The follow-up phone calls were conducted in 20 of those initially surveyed. Only 5 patients did not meet their goals. The following improvement areas were identified: need to provide medication lists and correct medication inaccuracies, need for medication review, patient goals documentation, and patient education and the appropriate medium of education. CONCLUSION: Future appointments for high-risk patients at the PCMH should include the pharmacist. The team should focus education on families/caregivers and utilize alternate patient education methods.

Prevalence of and factors associated with therapeutic failure-related hospitalizations in the elderly.

OBJECTIVE: A therapeutic failure (TF) is defined as a failure to accomplish the goals of treatment attributable to inadequate therapy, a drug-drug interaction that results in a subtherapeutic level for a drug, or medication nonadherence. The objective of this study was to evaluate the prevalence of and factors associated with TF-related hospitalizations in older adults. DESIGN: This investigation was a retrospective cohort study. SETTING: This study was conducted within a university-based hospital setting. PATIENTS: This investigation included patients with a primary care physician from the University of Pittsburgh Medical Center (UPMC) Senior Care Institute admitted to any UPMC hospital between September 1, 2011, and December 1, 2011. INTERVENTIONS: Chart abstracts of patient records were screened for a TF using a validated tool called the Therapeutic Failure Questionnaire (TFQ). Covariate data were also obtained. Descriptive statistics and bivariate analyses using Fisher's exact tests were conducted to assess the association between the covariates and the primary outcome. MAIN OUTCOME MEASURE(S): The primary outcome was the presence of a TF as measured by the TFQ. Secondary outcomes included associations between covariates and the presence of a TF. RESULTS: Of the 93 hospitalizations screened, 57 met inclusion criteria, and 18% of hospitalizations were as a result of preventable TFs. On bivariate analyses, both congestive heart failure (P = 0.03) and dependency for medication management (P = 0.04) were significantly associated with occurrence of TF. CONCLUSIONS: TFs are a potentially preventable cause of hospitalization in the elderly population and are commonly caused by omission of therapy.

Antihypertensive drug class use and differential risk of urinary incontinence in community-dwelling older women.

BACKGROUND: Medication use is a potentially reversible cause of urinary incontinence (UI). The objective of this longitudinal cohort study was to evaluate whether self-reported UI in community-dwelling older women is associated with the use of different classes of antihypertensive agents. METHODS: The sample consisted of 959 black and white women aged 72-81 years without baseline (Year 1) UI from the Health, Aging, and Body Composition Study. Use of any antihypertensive from 10 drug classes (ie, alpha blockers [central], alpha blockers [peripheral], angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, beta blockers, calcium channel blockers, diuretics [loop], diuretics [potassium-sparing], diuretics [thiazide], and vasodilators) was determined during Year 3 in-person interviews. The number of unique antihypertensive agents used and the standardized daily dosage were also examined. Self-reported UI, operationally defined as leaking urine at least weekly during the previous 12 months, was assessed at Year 4 visits. RESULTS: A total of 197 women (20.5%) reported UI at Year 4. Although any antihypertensive use, number of agents used, and standardized daily dosage at Year 3 were not associated with UI at Year 4, use of one particular drug class-peripheral alpha blockers (ie, doxazosin, prazosin, and terazosin)-was associated with fourfold greater odds of UI (adjusted odds ratio = 4.47; 95% confidence interval = 1.79-11.21; p = .0014). Further, in post hoc analyses, these odds nearly doubled in those also taking loop diuretics (adjusted odds ratio = 8.81; 95% confidence interval = 1.78-43.53; p = .0076). CONCLUSION: In community-dwelling older women, peripheral alpha blocker use was associated with UI, and the odds nearly doubled when used with loop diuretics.

Prevalence of potentially preventable unplanned hospitalizations caused by therapeutic failures and adverse drug withdrawal events among older veterans.

Background. Studies of drug-related hospitalizations have focused on adverse drug reactions, but few data are available on therapeutic failures (TFs) and adverse drug withdrawal events (ADWEs) leading to hospitalization among community-dwelling older adults. Thus, we sought to describe the prevalence of unplanned hospitalizations caused by TFs and ADWEs. In addition, we evaluated factors associated with these events in a nationally representative sample of older Veterans. Methods. This study included 678 randomly selected unplanned hospitalizations of older (age ≥ 65 years) Veterans between December 1, 2003, and November 9, 2006. The main outcomes were hospitalizations caused by a TF and/or an ADWE as determined by a pair of health professionals from review of medication charts and application of the Therapeutic Failure Questionnaire and/or Naranjo ADWE algorithm, respectively. Preventability (ie, medication error) of the admission was also assessed. Results. Thirty-four TFs and eight ADWEs involving 54 drugs were associated with 40 (5.9%) Veterans' hospitalizations; of these admissions, 90.0% (36/40) were rated as potentially preventable mostly due to medication nonadherence and suboptimal prescribing. The most common TFs that occurred were heart failure exacerbations (n = 8), coronary heart disease symptoms (n = 6), tachyarrhythmias (n = 3), and chronic obstructive pulmonary disease exacerbations (n = 3). Half (4/8) of the ADWEs that occurred were cardiovascular in nature. Multivariable logistic regression modeling indicated that black Veterans (adjusted odds ratio 2.92, 95% CI 1.25-6.80) were significantly more likely to experience a TF-related admission compared with white Veterans. Conclusions. TF-related unplanned hospitalizations occur more frequently than ADWE-related admissions among older Veterans. Almost all TFs and/or ADWEs are potentially preventable.

Comparing effectiveness of 3 learning strategies: simulation-based learning, problem-based learning, and standardized patients.

INTRODUCTION: Curricula must not only provide students with knowledge but also foster the development of critical thinking and reasoning skills. Several learning strategies, including problem-based learning (PBL), standardized patients, and high-fidelity human simulation, have been incorporated into courses; however, it is currently unknown which technique is the most effective. METHODS: This is a prospective, randomized, crossover study that was conducted during two 90-minute seizure disorder laboratory sessions for PharmD students in their third professional year. Students rotated between 3 different seizure disorder cases (A, B, and C), with each student experiencing 3 learning strategies including PBL, standardized patients, and high-fidelity human simulation. Evaluation of knowledge consisted of quizzes at the end of each case, and student perception and satisfaction were evaluated by an anonymous survey at the conclusion of the laboratory sessions. RESULTS: Student quiz scores from the simulation learning strategy were statistically better than those from the standardized interview and modified PBL (mPBL) strategies in cases A and B (P < 0.001). The student quiz scores for the standardized interview were also statistically better than the mPBL scores in case C (P = 0.001). When surveyed, 91% of students agreed or strongly agreed that simulation improved their knowledge, whereas only 69% and 67% of students agreed or strongly agreed that mPBL or standardized patients, respectively, improved their knowledge (P < 0.001). CONCLUSIONS: High-fidelity simulation is an effective learning strategy. When it is compared with standardized patients and mPBL strategies, students performed better on knowledge-based quizzes and had higher levels of satisfaction.

Prevalence of unplanned hospitalizations caused by adverse drug reactions in older veterans.

OBJECTIVES: To describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics. DESIGN: Retrospective cohort. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Six hundred seventy-eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006. MEASUREMENTS: Naranjo ADR algorithm, ADR preventability, and polypharmacy (0-4, 5-8, and ≥9 scheduled medications). RESULTS: Seventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta-blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin-converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health-status, and access-to-care variables, polypharmacy (≥9 and 5-8) was associated with greater risk of ADR-related hospitalization (adjusted odds ratio (AOR) = 3.90, 95% confidence interval (CI) = 1.43-10.61 and AOR = 2.85, 95% CI = 1.03-7.85, respectively). CONCLUSION: ADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy.

Analgesic use for knee and hip osteoarthritis in community-dwelling elders.

OBJECTIVE: To examine the prevalence and correlates of non-opioid and opioid analgesic use and descriptively evaluate potential undertreatment in a sample of community-dwelling elders with symptomatic knee and/or hip osteoarthritis (OA). DESIGN: Cross-sectional. SETTING: Health, Aging, and Body Composition Study. PATIENTS: Six hundred and fifty-two participants attending the year 6 visit (2002-03) with symptomatic knee and/or hip OA. OUTCOME MEASURES: Analgesic use was defined as taking ≥1 non-opioid and/or ≥1 opioid receptor agonist. Non-opioid and opioid doses were standardized across all agents by dividing the daily dose used by the minimum effective analgesic daily dose. Inadequate pain control was defined as severe/extreme OA pain in the past 30 days from a modified Western Ontario and McMaster Universities Osteoarthritis Index. RESULTS: Just over half (51.4%) reported taking at least one non-opioid analgesic and approximately 10% was taking an opioid, most (88.5%) of whom also took a non-opioid. One in five participants (19.3%) had inadequate pain control, 39% of whom were using <1 standardized daily dose of either a non-opioid or opioid analgesic. In adjusted analyses, severe/extreme OA pain was significantly associated with both non-opioid (adjusted odds ratio [AOR] = 2.44; 95% confidence interval [95% CI] = 1.49-3.99) and opioid (AOR = 2.64; 95% CI = 1.26-5.53) use. CONCLUSIONS: Although older adults with severe/extreme knee and/or hip OA pain are more likely to take analgesics than those with less severe pain, a sizable proportion takes less than therapeutic doses and thus may be undertreated. Further research is needed to examine barriers to optimal analgesic use.

The effect of medication use on urinary incontinence in community-dwelling elderly women.

OBJECTIVES: To evaluate whether use of certain medications with potential urological effects is associated with development of incident urinary incontinence in community-resident older women. DESIGN: Longitudinal cohort study. SETTING: Pittsburgh, PA, and Memphis, TN. PARTICIPANTS: Nine hundred fifty-nine healthy black and white women aged 65 and older enrolled in the Health, Aging and Body Composition Study without baseline (Year 1) self-reported urinary incontinence. MEASUREMENTS: Use of alpha blockers, anticholinergics, central nervous system medications (opioids, benzodiazepines, antidepressants, antipsychotics), diuretics (thiazide, loop, potassium sparing), and estrogen (all dosage forms) was determined during Year 3 interviews. Self-reported incident (≥ weekly) incontinence in during the previous 12 months was assessed at Year 4 interviews. RESULTS: Overall, 20.5% of these women reported incident incontinence at Year 4 (3 years from baseline). The most common medication used with potential urological activity was a thiazide diuretic (24.3%), followed by estrogen (22.2%); alpha blockers were the least commonly used (2.3%). Multivariable logistic regression analyses revealed that current users of alpha blockers (adjusted odds ratio (AOR)=4.98, 95% confidence interval (CI)=1.96-12.64) and estrogen (AOR=1.60, 95% CI=1.08-2.36) had a greater risk of urinary incontinence than nonusers. There was no greater risk (P>.05) of urinary incontinence with the current use of anticholinergics, central nervous system medications, or diuretics. No statistically significant race-by-medication use interactions were found (all P>.05). CONCLUSION: These results corroborate earlier reports that, in elderly women, use of alpha blockers or estrogens is associated with risk of self-reported incident urinary incontinence.

Central nervous system medication use and incident mobility limitation in community elders: the Health, Aging, and Body Composition study.

PURPOSE: To evaluate whether CNS medication use in older adults was associated with a higher risk of future incident mobility limitation. METHODS: This 5-year longitudinal cohort study included 3055 participants from the health, aging and body composition (Health ABC) study who were well-functioning at baseline. CNS medication use (benzodiazepine and opioid receptor agonists, antipsychotics, and antidepressants) was determined yearly (except year 4) during in-home or in-clinic interviews. Summated standardized daily doses (low, medium, and high) and duration of CNS drug use were computed. Incident mobility limitation was operationalized as two consecutive self-reports of having any difficulty walking 1/4 mile or climbing 10 steps without resting every 6 months after baseline. Multivariable Cox proportional hazard analyses were conducted adjusting for demographics, health behaviors, health status, and common indications for CNS medications. RESULTS: Each year at least 13.9% of participants used a CNS medication. By year 6, overall 49% had developed incident mobility limitation. In multivariable models, CNS medication users compared to never users showed a higher risk for incident mobility limitation (adjusted hazard ratio (Adj. HR) 1.28; 95% confidence interval (CI) 1.12-1.47). Similar findings of increased risk were seen in analyses examining dose- and duration-response relationships. CONCLUSIONS: CNS medication use is independently associated with an increased risk of future incident mobility limitation in community dwelling elderly. Further studies are needed to determine the impact of reducing CNS medication exposure on mobility problems.

Impact of a geriatric nursing home palliative care service on unnecessary medication prescribing.

BACKGROUND: There is a lack of studies concerning improvement of medication use in palliative care patients in nursing homes. OBJECTIVE: This study was conducted to evaluate whether a geriatric palliative care team reduced unnecessary medication prescribing for elderly veterans residing in a nursing home. METHODS: This was a retrospective, descriptive study of patients who died while residing in a geriatric palliative care unit between August 1, 2005, and July 31, 2007. Prescribed medications were evaluated using the Unnecessary Drug Use Measure, which contains 3 items from the Medication Appropriateness Index concerning lack of indication, lack of effectiveness, and therapeutic duplication. This measure was applied at 2 time points: on transfer/admission to the palliative care unit and at the last 30-day pharmacist medication review before death. Paired t tests and McNemar tests were used to compare medication use at these 2 points. RESULTS: Eighty-nine patients were included in the study. The majority were male (97.8%) and white (78.7%), with a mean (SD) age of 79.7 (7.8) years. The median length of stay on the unit was 39.0 days, and the mean number of chronic medical conditions was 8.4 (4.3). At baseline, the mean number of scheduled medications was 9.7 (4.3). The number of unnecessary medications per patient decreased from a mean of 1.7 (1.5) at admission to 0.6 (0.8) at closeout (P = 0.003). The decrease was seen in all 3 categories of the Unnecessary Drug Use Measure. CONCLUSIONS: The geriatric palliative care team was associated with a reduction in the number of unnecessary medications prescribed for older veterans in this nursing home. Future studies should evaluate the impact of decreasing unnecessary prescribing on clinical outcomes such as adverse drug reactions.

Number and dosage of central nervous system medications on recurrent falls in community elders: the Health, Aging and Body Composition study.

BACKGROUND: Few studies have examined the risk of multiple or high doses of combined central nervous system (CNS) medication use for recurrent falls in the elderly. The study objective was to evaluate whether multiple- or high-dose CNS medication use in older adults was associated with a higher risk of recurrent (>or=2) falls. METHODS: This longitudinal cohort study included 3,055 participants from the Health, Aging and Body Composition study who were well functioning at baseline. CNS medication use (benzodiazepine and opioid receptor agonists, antipsychotics, antidepressants) was determined annually (except Year 4) during in-person interviews. The number and summated standard daily doses (SDDs; low, medium, and high) of CNS medications were computed. Falls 1 year later were ascertained annually for 5 years. RESULTS: For a period of 5 years, as many as 24.1% of CNS medication users took 2+ agents annually, whereas as no more than 18.9% of CNS medication users took high doses annually (3+ SDDs). Yearly, as many as 9.7% of participants reported recurrent falls. Multivariable Generalized Estimating Equation analyses showed that multiple CNS medication users compared with never users had an increased risk of sustaining 2+ falls (adjusted odds ratio [OR] 1.95; 95% confidence interval [CI] 1.35-2.81). Those taking high (3+) CNS SDDs also exhibited an increased risk of 2+ falls (adjusted OR 2.89; 95% CI 1.96-4.25). CONCLUSIONS: Higher total daily doses of CNS medications were associated with recurrent falls. Further studies are needed to determine the impact of reducing the number of CNS medications and/or dosage on recurrent falls.

Effect of central nervous system medication use on decline in cognition in community-dwelling older adults: findings from the Health, Aging And Body Composition Study.

OBJECTIVES: To evaluate whether combined use of multiple central nervous system (CNS) medications over time is associated with cognitive change. DESIGN: Longitudinal cohort study. SETTING: Pittsburgh, Pennsylvania, and Memphis, Tennessee. PARTICIPANTS: Two thousand seven hundred thirty-seven healthy adults (aged > or =65) enrolled in the Health, Aging and Body Composition study without baseline cognitive impairment (modified Mini-Mental State Examination (3MS) score > or =80). MEASUREMENTS: CNS medication (benzodiazepine- and opioid-receptor agonists, antipsychotics, antidepressants) use, duration, and dose were determined at baseline (Year 1) and Years 3 and 5. Cognitive function was measured using the 3MS at baseline and Years 3 and 5. The outcome variables were incident cognitive impairment (3MS score <80) and cognitive decline (> or =5-point decline on 3MS). Multivariable interval-censored survival analyses were conducted. RESULTS: By Year 5, 7.7% of subjects had incident cognitive impairment; 25.2% demonstrated cognitive decline. CNS medication use increased from 13.9% at baseline to 15.3% and 17.1% at Years 3 and 5, respectively. It was not associated with incident cognitive impairment (adjusted hazard ratio (adj HR)=1.11, 95% confidence interval (CI)=0.73-1.69) but was associated with cognitive decline (adj HR 1.37, 95% CI=1.11-1.70). Longer duration (adj HR=1.39, CI=1.08-1.79) and higher doses (>3 standardized daily doses) (adj HR=1.87, 95% CI=1.25-2.79) of CNS medications suggested greater risk of cognitive decline than with nonuse. CONCLUSION: Combined use of CNS medications, especially at higher doses, appears to be associated with cognitive decline in older adults. Future studies must explore the effect of combined CNS medication use on vulnerable older adults.

Epidemiology of medication-related adverse events in nursing homes.

BACKGROUND: Nursing home residents are prescribed more medications than patients in any other clinical setting. Although pharmacotherapy for older nursing home residents is usually safe and effective, it can lead to medication-related adverse events such as adverse drug reactions (ADRs), adverse drug withdrawal events (ADWEs), and therapeutic failures (TFs). OBJECTIVE: This article reviews the descriptive (incidence) and analytic (risk factor) epidemiology of medication-related adverse events occurring in nursing home residents as reported in the literature during the last 2 decades. METHODS: A search of MEDLINE and International Pharmaceutical Abstracts was conducted for articles published in English between January 1986 and July 2006 using the following terms: adverse drug events, adverse drug reactions, adverse drug withdrawal events, aged, drug therapy, drug-related problems, medication-related problems, nursing homes, therapeutic failures, and treatment failures. The reference lists of identified articles, recent review articles, book chapters, and the authors' reference library were also searched manually. RESULTS: Seven studies met the inclusion and exclusion criteria and were included in this review. Five studies described ADRs, 1 described ADWEs, and 1 described TFs. The studies of ADRs used different methods of detecting ADRs, resulting in incidence rates ranging from 1.19 to 7.26 per 100 resident-months. The single study of ADWEs reported an incidence of 2.60 per 100 resident-months. An incidence rate for the single study describing TFs could not be calculated. CONCLUSIONS: Medication-related adverse events are common in the nursing home setting. Additional studies are needed to enhance the detection and prevention of medication-related adverse events and to reduce their impact on residents' outcomes and health care costs.