Hormone Replacement: The Fountain of Youth?

Natural aging brings reduced production of growth and sex hormones, beginning in middle age, with noticeable physiologic changes by the sixth or seventh decade of life: reduced muscle mass, energy, and exercise capacity and alterations in sexual function. Hormones and hormone precursors have been investigated to delay changes in body composition, strength, and physical and cognitive function. Menopausal hormone therapy is effective for vasomotor and genitourinary symptoms. Testosterone is effective in men with hypogonadism and declines in physiologic function. The lack of clinical studies evaluating the long-term effects and risks of hormone replacement limits its use.

Older patient, physician and pharmacist perspectives about community pharmacists' roles.

OBJECTIVES: To investigate older patient, physician and pharmacist perspectives about the role of pharmacists in pharmacist-patient interactions. METHODS: Eight focus-group discussions were held in senior centres, community pharmacies and primary care physician offices. Participants were 42 patients aged 63 years and older, 17 primary care physicians and 13 community pharmacists. Qualitative analysis of the focus-group discussions was performed. KEY FINDINGS: Participants in all focus groups indicated that pharmacists are a good resource for basic information about medications. Physicians appreciated pharmacists' ability to identify drug interactions, yet did not comment on other specific aspects related to patient education and care. Physicians noted that pharmacists often were hindered by time constraints that impeded patient counselling. Both patient and pharmacist participants indicated that patients often asked pharmacists to expand upon, reinforce and explain physician-patient conversations about medications, as well as to evaluate medication appropriateness and physician treatment plans. These groups also noted that patients confided in pharmacists about medication-related problems before contacting physicians. Pharmacists identified several barriers to patient counselling, including lack of knowledge about medication indications and physician treatment plans. CONCLUSIONS: Community-based pharmacists may often be presented with opportunities to address questions that can affect patient medication use. Older patients, physicians and pharmacists all value greater pharmacist participation in patient care. Suboptimal information flow between physicians and pharmacists may hinder pharmacist interactions with patients and detract from patient medication management. Interventions to integrate pharmacists into the patient healthcare team could improve patient medication management.

Which providers should communicate which critical information about a new medication? Patient, pharmacist, and physician perspectives.

OBJECTIVES: To investigate older patient, pharmacist, and physician perspectives about what information is essential to impart to patients receiving new medication prescriptions and who should provide the information. DESIGN: Qualitative focus group discussions. SETTINGS: Senior centers, retail pharmacies, and primary care physician offices. PARTICIPANTS: Forty-two patients aged 65 and older, 13 pharmacists, and 17 physicians participated in eight focus groups. MEASUREMENT: Qualitative analysis of transcribed focus group interviews and consensus through iterative review by multidisciplinary auditors. RESULTS: Patient, pharmacist, and physician groups all affirmed the importance of discussing medication directions and side effects and said that physicians should educate about side effects and that pharmacists could adequately counsel about certain important issues. However, there was substantial disagreement between groups about which provider could communicate which critical elements of medication-related information. Some pharmacists felt that they were best equipped to discuss medication-related issues but acknowledged that many patients want physicians to do this. Physicians tended to believe that they should provide most new-medication education for patients. Patients had mixed preferences. Patients aged 80 and older listed fewer critical topics of discussion than younger patients. CONCLUSION: Patients, pharmacists, and physicians have incongruent beliefs about who should provide essential medication-related information. Differing expectations could lead to overlapping, inefficient efforts that result in communication deficiencies when patients receive a new medication. Collaborative efforts to ensure that patients receive complete information about new medications could be explored.

Geriatric pharmacy education: a strategic plan for the future.

The aging of the US population will have a major effect on the future practice of pharmacy. By 2030, 20% of Americans will be aged 65 years and older, an increase from 12.4% in 2000. A challenge to colleges and schools of pharmacy in the 21st century is to prepare students and practitioners to meet the growing pharmaceutical care needs of the older adult population and to meet these needs in a variety of care settings. This paper reviews the present state of geriatric pharmacy education and training, including strategies for ensuring that practicing pharmacists will have adequate knowledge, skills, attitudes, and values to provide this care. Secondly, this report provides strategic directions and recommendations for successfully implementing geriatrics curricula at an institutional level.

Reaching the homebound elderly: the Prescription Intervention and Lifelong Learning (PILL) program.

This article describes the Prescription Intervention and Lifelong Learning (PILL) program, a three-year pilot project to develop in-home pharmacy care services to clients of a community-based social service agency. Clients who were homebound, at least 62 years of age, and taking at least five medications were eligible for inclusion. Potential participants were referred by care managers to the pharmacist, who conducted an in-home evaluation of the medication regimen and assessed the risk for medication-related problems. The pharmacist provided instruction for hypertension and diabetes mellitus self-monitoring, extensive medication counseling for clients with complex medications regimens, and conducted other activities to promote positive medication- related outcomes. The clients served were primarily female, between 70 and 90 years of age, and almost one-half lived alone. They were taking an average of more than nine medications daily, and had at least one chronic disease. The clients of the social service agency were highly vulnerable to medication-related problems and were in need of in-home pharmacy care services.

Medication use and prescribing considerations for elderly patients.

Older adults consume more medications than any other segment of the population. Increasing lifespan means that more people will live into old age, frequently with disabilities and conditions man-aged by medications. Age-associated physiologic changes, medication use patterns, and adverse drug effects and interactions place the older adult at high risk for medication-related problems. Older adults living in institutions, those with complex medical problems,and those who do not adhere to medication regimens are at highest risk for negative health outcomes from medication mishaps. Dentists must be able to identify older adults who are susceptible to adverse drug events and to recognize which medications are most likely to precipitate problems.

The impact of mirtazapine compared with non-TCA antidepressants on weight change in nursing facility residents.

OBJECTIVE: To examine weight change associated with the use of mirtazapine compared with other antidepressants in elderly, depressed nursing facility residents. DESIGN: Retrospective cohort study. SETTING: Long-term care nursing facilities in the Southern California region. PARTICIPANTS: One hundred eighty-nine elderly patients (>65 years of age) who had a new episode or diagnosis of depression and stayed in the same facility for at least eight months. METHODS: The impact of antidepressant use on weight change and percentage weight change at three months and six months were assessed using Ordinary Least Squares (OLS) regression analysis. Mirtazapine served as the comparator drug. RESULTS: We found no statistically significant differences in weight change at three months and at six months between mirtazapine and all other nontricyclic antidepressants except for fluoxetine, which was associated with a gain of 3.8 pounds relative to mirtazapine at three months (P = 0.05). However, a hypertension diagnosis was associated with significant weight gain at three months (2.2 lbs., P = 0.04 or +1.7%, P = 0.03) and at six months (3.9 lbs., P = 0.005 or +3%, P = 0.006). A diagnosis of diabetes was associated with weight loss at six months (-3.7 lbs., P = 0.03; -3.2%, P = 0.02). Baseline weight was associated with increased weight loss in women at six months (-0.09 lb (per lb. baseline), P = 0.03). CONCLUSIONS: With the exception of fluoxetine, our study showed that the impact on weight using mirtazapine was not statistically different from other nontricyclic antidepressant users after controlling for factors such as baseline weight, gender, dose, and comorbid diagnoses.

A review of rivastigmine: a reversible cholinesterase inhibitor.

BACKGROUND: Rivastigmine tartrate is a reversible cholinesterase inhibitor indicated for the symptomatic treatment of mild to moderate dementia. It was approved by the US Food and Drug Administration for the treatment of Alzheimer's disease (AD) on April 21, 2000. OBJECTIVE: The purpose of this review was to summarize the background on dementia of the Alzheimer type and the pharmacokinetic properties, efficacy and tolerability profiles, clinical applications, adverse effects (AEs), drug interactions, and pharmacoeconomics of rivastigmine. METHODS: A literature search was conducted using MEDLINE (1995-2002), EMBASE Geriatrics and Gerontology (1995-2002), the National Institutes of Health Alzheimer's Disease Education and Resource Center Combined Health Information Database, and Google. Search terms included rivastigmine, Exelon, ENA 713, and ENA-713. The bibliographies of retrieved articles also were searched for relevant articles. RESULTS: In clinical trials, rivastigmine has improved or maintained cognitive function, global function (ie, activities of daily living [ADLs]), and behavior in patients with mild to moderate AD for up to 52 weeks. AEs are generally mild to moderate and primarily affect the gastrointestinal (GI) tract. Clinically significant drug interactions with rivastigmine have thus far not been reported. Treatment with rivastigmine for up to 2 years may reduce the cost of caring for patients with AD. Cost savings are minimal during the first year, particularly for those with mild disease, but increase during the second year of treatment. Cost savings occur earlier for those with moderate AD. Most savings are realized from a delay in the need for institutionalization. CONCLUSIONS: Rivastigmine has been shown to improve or maintain patients' performance in 3 major domains: cognitive function, global function (ADLs), and behavior. The efficacy and tolerability of rivastigmine have been proved by numerous clinical trials, with the most prominent AE being GI irritation.

Cardiovascular drug therapy in the elderly: theoretical and practical considerations.

The elderly population is expanding rapidly throughout the world. Hypertension, heart disease and other cardiovascular disorders are prevalent conditions among this age group. Consequently, clinicians will spend a large proportion of their practices managing older adults with cardiovascular disorders. A large proportion of this time will be devoted to using pharmacotherapeutic strategies for the long-term management of chronic conditions. The physiological changes that accompany aging affect cardiovascular function, and the pharmacokinetics and pharmacodynamics of many cardiovascular medications are altered by these physiological changes. The interactions of these changes can have a profound effect on the agents used to treat cardiovascular disorders and may alter their therapeutic outcomes. Several classes of medications are used to treat chronic cardiovascular disorders in older adults. These include the ACE inhibitors and angiotensin II receptor antagonists, calcium channel antagonists, beta-adrenoceptor antagonists (beta-blockers), oral antiarrhythmic agents and warfarin. Drugs such as beta-blockers may aggravate decreased cardiac output and increase peripheral resistance, but are valuable adjuncts in many patients with congestive heart failure. Agents that reduce angiotensin II activity may have several benefits for treating heart failure and hypertension. Successful treatment of cardiovascular disorders in older adults requires the choice of the most appropriate agent, taking into consideration the complex interactions of pharmacokinetics, pharmacodynamics and disease effects.