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1.
J Gen Intern Med ; 34(7): 1220-1227, 2019 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-30972554

RESUMEN

BACKGROUND: Polypharmacy and potentially inappropriate medications (PIMs) are increasingly common and associated with adverse health effects. However, post-graduate education in polypharmacy and complex medication management for older adults remain limited. OBJECTIVE: The Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) polypharmacy clinic was created to provide a platform for teaching internal medicine (IM) and nurse practitioner (NP) residents about outpatient medication management and deprescribing for older adults. We aimed to assess residents' knowledge of polypharmacy and perceptions of this interprofessional education intervention. DESIGN: A prospective cohort study with an internal comparison group. PARTICIPANTS: IM residents and NP residents; Veterans ≥ 65 years and taking ≥ 10 medications. INTERVENTION: IMPROVE consists of a pre-clinic conference, shared medical appointment, individual appointment, and interprofessional precepting model. MAIN MEASURES: We assessed residents' performance on a pre-post knowledge test, residents' qualitative assessment of the educational impact of IMPROVE, and the number and type of medications discontinued or decreased. KEY RESULTS: The IMPROVE intervention group (n = 18) had a significantly greater improvement in test scores than the control group (n = 18) (14% ± 15% versus - 1.3% ± 16%) over a period of 6 months (Wilcoxon rank sum, p = 0.019). In focus groups, residents (n = 17) reported perceived improvements in knowledge and skills, noting that the experience changed their practice in other clinical settings. In addition, residents valued the unique interprofessional experience. Veterans (n = 71) had a median of 15 medications (IQR 12-19), and a median of 2 medications (IQR 1-3) was discontinued. Vitamins, supplements, and cardiovascular medications were the most commonly discontinued medications, and cardiovascular medications were the most commonly decreased in dose or frequency. CONCLUSIONS: Overall, IMPROVE is an effective model of post-graduate primary care training in complex medication management and deprescribing that improves residents' knowledge and skills, and is perceived by residents to influence their practice outside the program.

2.
Trials ; 18(1): 239, 2017 05 26.
Artículo en Inglés | MEDLINE | ID: mdl-28549471

RESUMEN

BACKGROUND: Diabetes shared medical appointments (SMAs) and reciprocal peer support programs have been found in efficacy trials to help adults with diabetes improve their self-management and achieve short-term gains in clinical and patient-centered outcomes. In order to translate this evidence to system-level interventions, there is a need for large-scale, pragmatic trials that examine the effectiveness, implementation, and costs of SMAs and reciprocal peer support across diverse settings. METHODS: The Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study is a multisite, cluster randomized trial that is evaluating the effectiveness and implementation of SMAs with and without an additional reciprocal Peer-to-Peer (P2P) support program, when compared to usual care. The P2P program comprises periodic peer support group sessions and telephone contact between SMA participant pairs to promote more effective diabetes self-management. We will examine outcomes across three different treatment groups: (1) SMAs, (2) SMAs plus P2P, and (3) usual care. We will collect and analyze data over a 2.5-year implementation period at five geographically diverse Veterans Affairs (VA) health systems. The primary outcome is the relative change in hemoglobin A1c over time. Secondary outcomes are changes in systolic blood pressure, antihypertensive medication use, statin use, and insulin initiation over the study period. The unit of analysis is the individual, adjusted by the individual's SMA group (the cluster). We will use mixed methods to rigorously evaluate processes and costs of implementing these programs in each of the clinic settings. DISCUSSION: We hypothesize that patients will experience improved outcomes immediately following participation in SMAs and that augmenting SMAs with reciprocal peer support will help to maintain these gains over time. The results of this study will be among the first to examine the effects of diabetes SMAs alone and in conjunction with P2P in a range of real-life clinical settings. In addition, the study will provide important information on contextual factors associated with successful program implementation. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02132676 . Registered on 21 August 2013.


Asunto(s)
Citas y Horarios , Diabetes Mellitus/terapia , Grupo Paritario , Autocuidado , Apoyo Social , Biomarcadores/sangre , Diabetes Mellitus/sangre , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/psicología , Hemoglobina A Glucada/metabolismo , Humanos , Cooperación del Paciente , Proyectos de Investigación , Teléfono , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , United States Department of Veterans Affairs
3.
Am J Health Syst Pharm ; 73(4): 229-34, 2016 Feb 15.
Artículo en Inglés | MEDLINE | ID: mdl-26843500

RESUMEN

PURPOSE: Results of a survey assessing opportunities for geriatrics training currently available to pharmacy residents and residency directors' views on the concept of a defined slate of required geriatrics rotations are reported. METHODS: Directors of postgraduate year 1 (PGY1) pharmacy residency programs (n = 368) and postgraduate year 2 (PGY2) geriatric pharmacy residencies (n = 13) were surveyed regarding current training opportunities in geriatrics. PGY2 residency directors were invited to participate in a follow-up survey to identify high-priority areas for possible standardization of residency requirements on clinical rotations in geriatric practice settings. RESULTS: About 21% of the PGY1 residency directors who responded to the survey indicated that their program required a geriatrics rotation, and 47% reported elective geriatrics rotations. All 13 PGY2 geriatric pharmacy residencies represented in the survey offered a long-term care rotation, with 12 offering rotations in mental health and outpatient geriatrics, 11 offering a hospice/palliative care rotation, and 10 offering a rotation in inpatient geriatrics. All 11 PGY2 directors who responded to the follow-up survey supported requiring a long-term care rotation in future revisions of the ASHP accreditation standard for geriatric pharmacy residencies; 10 supported required rotations in inpatient and outpatient geriatrics, and 9 supported requiring a hospice/palliative care rotation. CONCLUSION: Geriatrics-oriented training in PGY1 pharmacy residencies is limited, with only about one in five programs requiring a geriatrics rotation. The survey results indicated broad support among PGY2 program heads for required rotations in various geriatric healthcare settings.


Asunto(s)
Geriatría/organización & administración , Residencias en Farmacia/organización & administración , Servicio de Farmacia en Hospital/organización & administración , Estudiantes de Farmacia , Acreditación , Humanos , Cuidados a Largo Plazo/organización & administración , Cuidados Paliativos/organización & administración , Farmacéuticos/organización & administración , Residencias en Farmacia/estadística & datos numéricos , Sociedades Farmacéuticas , Encuestas y Cuestionarios , Estados Unidos
5.
J Am Geriatr Soc ; 62(11): 2185-90, 2014 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-25369755

RESUMEN

Surgery is common in older adults, so geriatric and surgical providers need to develop expertise in the care of older adults undergoing surgery. The Co-management of Older Operative Patients En Route Across Treatment Environments (CO-OPERATE) program is a clinical and educational collaboration between geriatrics and several surgical specialties at Veterans Affairs Health Care Connecticut. Individuals in CO-OPERATE are co-managed during the pre-, peri-, and postoperative periods. General surgery, urology, vascular surgery, orthopedics, cardiothoracic surgery and neurosurgery all participate in the program, with geriatrics expertise provided by a geriatrician, geriatric nurse practitioner and a geriatric clinical pharmacist. In the initial 3 years, there were 211 CO-OPERATE participants; 31% were evaluated preoperatively, and 62% of the individuals seen preoperatively were seen in clinic. There was a median of three recommendations per consultation. At discharge, 56% returned to the community. Individuals seen preoperatively were more likely to return to the community (63%) than those seen after surgery (50%, P = .10). Geriatrics co-management with a variety of surgical specialties is feasible and may be associated with higher rates of discharge back to the community.


Asunto(s)
Conducta Cooperativa , Anciano Frágil , Comunicación Interdisciplinaria , Grupo de Atención al Paciente/organización & administración , Atención Perioperativa/métodos , Actividades Cotidianas/clasificación , Anciano , Anciano de 80 o más Años , Comorbilidad , Connecticut , Evaluación de la Discapacidad , Femenino , Geriatría/organización & administración , Hospitales Universitarios , Hospitales de Veteranos , Humanos , Tiempo de Internación , Masculino , Alta del Paciente , Especialidades Quirúrgicas/organización & administración
7.
Drugs Aging ; 30(7): 513-25, 2013 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-23591934

RESUMEN

The objective of this review was to compare the safety and efficacy of dabigatran, rivaroxaban and apixaban to warfarin for the management of atrial fibrillation (AF) in older adults. The prevalence and incidence of AF increase with age. Approximately 5 % of the United States population over the age of sixty-five years and 10 % over the age of seventy-nine years have AF. AF is associated with increased risk for thromboembolic events. Despite the increasing incidence and prevalence of AF in older adults and the risks of thromboembolic events, clinicians often avoid anticoagulants. Specifically with warfarin, the risk of hemorrhage may outweigh the benefit in stroke risk reduction in certain populations. Aspirin, while safer to use, is not as effective as warfarin in stroke risk reduction. Newer non-vitamin K dependent antithrombotic therapies (e.g. dabigatran, rivaroxaban, and apixaban) are redefining thromboprophylaxis of AF. Dabigatran, rivaroxaban, and apixaban are at least as effective as warfarin in stroke risk reduction. With new mechanisms of action and no need for therapeutic drug monitoring, countless new patients are potential candidates for anticoagulation. However patient adherence, lack of a reversal agent, cost, and other safety concerns remain reasons for caution and careful consideration. Furthermore, older adults exhibited greater adverse effects from these agents across the clinical trials. This review will examine the newer anticoagulants safety and efficacy with particular attention to their role in treating older adults with AF. Alternatives to warfarin therapy now exist for thromboprophylaxis of AF. Whether these agents represent advances in overall safety in older adults remains uncertain. More experience and research are needed before endorsing their widespread use as a replacement for warfarin in the geriatric population.


Asunto(s)
Fibrilación Atrial/tratamiento farmacológico , Bencimidazoles/uso terapéutico , Fibrinolíticos/uso terapéutico , Morfolinas/uso terapéutico , Pirazoles/uso terapéutico , Piridonas/uso terapéutico , Tiofenos/uso terapéutico , Warfarina/uso terapéutico , beta-Alanina/análogos & derivados , Anciano , Bencimidazoles/efectos adversos , Dabigatrán , Interacciones de Drogas , Fibrinolíticos/efectos adversos , Humanos , Morfolinas/efectos adversos , Pirazoles/efectos adversos , Piridonas/efectos adversos , Medición de Riesgo , Rivaroxabán , Tiofenos/efectos adversos , Warfarina/efectos adversos , beta-Alanina/efectos adversos , beta-Alanina/uso terapéutico
8.
Consult Pharm ; 28(2): 99-109, 2013 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-23395810

RESUMEN

OBJECTIVE: To determine the utility (i.e., positive predictive value [PPV] and time requirement) of an adverse drug event (ADE) trigger tool in Veterans Affairs (VA) nursing facilities and to describe the most common types of potential ADEs detected with the trigger tool. DESIGN: Retrospective chart review. SETTING/PATIENTS: Veterans residing in three VA nursing facilities between September 29, 2010, and October 29, 2010. MEASUREMENT: We used the Institute for Healthcare Improvement-endorsed nursing facility ADE trigger tool, modified to enhance its clinical relevance to detect potential ADEs. Electronic medical records were screened to identify residents with one or more abnormal laboratory values specified in the trigger tool. MAIN OUTCOME MEASURES: A potential ADE was defined as the concurrent administration of medication that could cause the abnormal laboratory value. An overall PPV, or proportion of residents with an abnormal laboratory value who had a potential ADE, and average time required to complete each trigger tool assessment, were calculated. RESULTS: Among 321 veterans, 50.5% (n = 162) had at least one abnormal laboratory value contained in the trigger tool. Ninety-nine potential ADEs involving 146 medications were detected in 65 veterans. The overall PPV of the ADE trigger tool was 40.1% (65/162), and the average time to complete resident assessments was 8.8 (standard deviation ± 5.7) minutes. The most common potential ADEs were acute kidney injury (n = 30 residents), hypokalemia (n = 18), hypoglycemia (n = 13), and hyperkalemia (n = 10). CONCLUSIONS: The modified nursing facility trigger tool was shown to be an effective and efficient method for detecting potential ADEs.


Asunto(s)
Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/diagnóstico , Casas de Salud , Anciano , Anciano de 80 o más Años , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/epidemiología , Registros Electrónicos de Salud , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Tiempo , Estados Unidos , United States Department of Veterans Affairs , Veteranos
9.
J Pharm Technol ; 28(4): 156-162, 2012 Jul 01.
Artículo en Inglés | MEDLINE | ID: mdl-24660166

RESUMEN

BACKGROUND: Medication complexity is a large determinant of adherence. Few studies have explored the relationship between cognitive impairment and medication complexity. OBJECTIVE: To evaluate whether cognitive impairment is associated with medication complexity for prescription and over-the-counter (OTC) medications. METHODS: In this cross-sectional analysis, we studied the association between cognitive impairment and the complexity of prescription and OTC drug regimens. Baseline participants were from the Health, Aging and Body Composition study, consisting of 3075 well-functioning 70- to 79-year-old black and white men and women. Cognitive impairment was defined by having a Modified Mini-Mental State Examination score <80. The complexity of prescription and OTC (including supplements/herbals) medications was assessed using a modified version of the Medication Regimen Complexity Index (mMRCI). The mMRCI score increases with complexity of dosage forms, number of medications, pill burden, and nondaily dosing. RESULTS: The mean (SD) age was 74 (2.9) years (n = 3055; 52% female, 41% black). The median prescription mMRCI score was 6 (range 0-66). The median OTC mMRCI score was 4 (range 0-71). Adjusting for health status, demographics, and access to care, medication complexity was lower in participants with cognitive impairment for prescription (adjusted RR 0.89; 95% CI 0.80 to 0.99) and OTC medications (adjusted RR 0.76; 95% CI 0.64 to 0.93) compared to those without cognitive impairment. The number of prescription medications was not different, but the number of OTC drugs was lower for those with cognitive impairment. CONCLUSIONS: In this cohort of well-functioning older adults, those with cognitive impairment had lower prescription complexity due to less-complex dosage forms, pill burden, or daily dosing. OTC complexity was also lower, primarily due to a lower number of OTC drugs. The results of this study show that further research on medication complexity and adherence and health outcomes in cognitively impaired individuals is warranted.

10.
Consult Pharm ; 26(9): 665-71, 2011 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-21896473

RESUMEN

An 84-year-old male with stage III chronic kidney disease and a history of multiple psychiatric and medical disorders presented to the emergency department (ED) with new onset proximal leg weakness with tremor upon standing, truncal ataxia, and myoclonic jerks of the upper extremity that had progressively worsened over three weeks. Magnetic resonance imaging and head computed tomography showed no acute change from baseline. After admission, the patient reported visual hallucinations, vertigo, and slurred speech, and displayed nocturnal agitation/delirium. These symptoms were managed with risperidone. Prior to admission, the most recent medication change was the initiation of bupropion 100 mg extended-release twice daily. Bupropion was titrated to 150 mg twice daily over the three weeks prior to the ED visit. Gradual tapering of the bupropion dose was started after admission. Symptoms of agitation, delirium, speech, and motor disturbances decreased 36 to 48 hours after bupropion dose was lowered to 75 mg daily, and risperidone was changed to quetiapine. The patient was discharged to short-term rehabilitation with return of mental status to baseline. Bupropion and quetiapine were discontinued at discharge from the rehabilitation center. Case reports exist for acute psychotic and parkinsonian symptoms after administration of bupropion and bupropion extended-release, but none exist for the combination of focal neurologic deficits and psychotic symptoms found in this patient's presentation. Limited pharmacokinetic data in the elderly and those with renal impairment suggest that this patient population may have reduced clearance of bupropion. Dose adjustment should be considered in such patients and signs of toxicity closely monitored. Adverse reactions to bupropion should be considered if a patient presents with acute neurologic or psychotic symptoms after initiation or dose modification of bupropion.


Asunto(s)
Ataxia/inducido químicamente , Bupropión/efectos adversos , Psicosis Inducidas por Sustancias/etiología , Temblor/inducido químicamente , Anciano de 80 o más Años , Humanos , Masculino
11.
J Am Geriatr Soc ; 58(8): 1475-80, 2010 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-20662956

RESUMEN

OBJECTIVES: To describe the quality of warfarin prescribing and monitoring in Veterans Affairs (VA) nursing homes and to assess the factors associated with maintaining a therapeutic international normalized ratio (INR). DESIGN: Retrospective cohort. SETTING: Five VA nursing homes. PARTICIPANTS: All veterans who received warfarin between January 1 and June 30, 2008, at the nursing homes. MEASUREMENTS: Using medical records, the percentage of person-time spent in the target INR range, the proportion of patients with INRs in the therapeutic range on 50% or more of their person-days, and the frequency of INR monitoring were estimated. Multivariable logistic regression was used to identify factors associated with maintaining a therapeutic INR 50% or more of the time. RESULTS: Over 6 months, 160 patients received 10,380 person-days of warfarin. INRs were in the therapeutic range for 55% of the person-days, and 99% of the INR tests were repeated within 4 weeks of the previous result. On an individual level, 49% of patients had INRs in the target range for 50% or more of their person-days. Achieving this outcome was more likely in patients with prevalent warfarin use than with new use (adjusted odds ratio (AOR)=2.86, 95% confidence interval (CI)=1.06-7.72). Conversely, patients with a history of a stroke (AOR=0.38, 95% CI =0.18-0.80) were less likely to have therapeutic INRs for 50% or more of their days. CONCLUSION: Warfarin appears to be prescribed and monitored effectively in VA nursing home patients. Future studies should focus on increasing time in therapeutic range in patients with poor INR control.


Asunto(s)
Anticoagulantes/administración & dosificación , Relación Normalizada Internacional , Garantía de la Calidad de Atención de Salud , Warfarina/administración & dosificación , Anciano , Estudios de Cohortes , Monitoreo de Drogas , Femenino , Hemorragia/epidemiología , Humanos , Masculino , Casas de Salud , Estudios Retrospectivos , Accidente Cerebrovascular/sangre , Estados Unidos/epidemiología , United States Department of Veterans Affairs
12.
Consult Pharm ; 24(2): 134-45, 2009 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-19275455

RESUMEN

Beginning January 1, 2011 the first of the baby boomers will turn 65 years of age. One of the biggest challenges they will encounter is deciding where they wish to live. Faced with uncertainty regarding their health, longevity, expenses, and need for supportive services, many older adults are overwhelmed with selecting long-term care options. Today, there are a variety of living arrangements available to seniors. These range from independent living to home care or day care, congregate housing, assisted living or nursing facilities. With the number of adults 65 years of age and older projected to exceed 80 million by 2030, there also is a growing concern over the availability of these housing options. Furthermore, as the Institute of Medicine report, "Retooling for an Aging America," notes there will be an additional need for qualified professionals to care for older adults. Pharmacists are uniquely qualified and positioned to provide these services. This article describes various types of living arrangements available to the older adults and the issues associated with transitioning from one setting to another setting. Opportunities for pharmacists to consult in the emerging continuum of care marketplace also will be discussed.


Asunto(s)
Actividades Cotidianas , Servicios de Salud para Ancianos/organización & administración , Servicios de Atención de Salud a Domicilio/organización & administración , Viviendas para Ancianos , Acontecimientos que Cambian la Vida , Servicios Farmacéuticos/organización & administración , Anciano , Anciano de 80 o más Años , Necesidades y Demandas de Servicios de Salud , Humanos , Estados Unidos
13.
Ann Pharmacother ; 36(3): 433-6, 2002 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-11895055

RESUMEN

OBJECTIVE: To report a case of successful treatment of refractory hot flashes with gabapentin in a patient with prostate cancer who was receiving combination antiandrogen and gonadotropin hormone-releasing hormone (GnRH) analog therapy. CASE SUMMARY: A 70-year-old white man with a history of advancing prostate cancer experienced disabling hot flashes from combination therapy with the antiandrogen bicalutamide and the GnRH analog goserelin acetate. He failed to respond to clonidine 0.1 mg twice daily, megestrol acetate 40 mg/d, diethylstilbestrol 1 mg/d, and venlafaxine 25 mg twice daily. The patient was then treated with gabapentin 600 mg once daily, at which time he experienced near-complete resolution of his symptoms. DISCUSSION: This case supports a previous report of the marked improvement in severity and duration of hot flashes associated with antiandrogen or GnRH analog therapy in prostate cancer. The mechanism by which gabapentin reduces hot flashes is unknown. CONCLUSIONS: Hot flashes resulting from antiandrogen or GnRH analog therapy are often difficult to treat and leave many patients disabled. Gabapentin has been shown to markedly reduce the severity, frequency, and duration of these hot flashes. Controlled trials are necessary to evaluate gabapentin against other therapeutic modalities.


Asunto(s)
Acetatos/uso terapéutico , Aminas , Antagonistas de Andrógenos/efectos adversos , Ácidos Ciclohexanocarboxílicos , Antagonistas de Aminoácidos Excitadores/uso terapéutico , Hormona Liberadora de Gonadotropina/efectos adversos , Sofocos/tratamiento farmacológico , Neoplasias de la Próstata/tratamiento farmacológico , Ácido gamma-Aminobutírico , Anciano , Antagonistas de Andrógenos/uso terapéutico , Gabapentina , Hormona Liberadora de Gonadotropina/uso terapéutico , Sofocos/inducido químicamente , Humanos , Masculino
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