Assessing students' knowledge regarding the roles and responsibilities of a pharmacist with focus on care transitions through simulation.

BACKGROUND AND PURPOSE: To evaluate the impact of a pharmacist-focused transitions of care (TOC) simulation on students' perceptions and knowledge of pharmacist roles in the healthcare continuum. Educational Activity and Setting: Two simulations, highlighting pharmacist roles in various practice settings, were conducted within the Pharmaceutical Skills courses in the third-year doctor of pharmacy curriculum. Patient cases were built utilizing electronic medical records (EMR). Students' knowledge was assessed before and after the simulations regarding pharmacist involvement in medication reconciliation, reduction in patient readmissions, reduction of inappropriate medication use, roles and communication on an interprofessional team, and involvement with health information technology (HIT) during care transitions. FINDINGS: Fifty-one third-year pharmacy students were anonymously evaluated prior to and following the simulation to assess changes in knowledge and perceptions during the fall semester. Thirty-two (62.7%) students completed the pre-simulation and 21 (41.2%) students completed the post-simulation assessments, respectively. In the spring semester, 40 (80%) students completed the pre-simulation and 23 (46%) students finished the post-simulation assessments. Students predominately had community pharmacy work experience (n=28, 55%). Overall, students enjoyed the variety of pharmacist-led encounters throughout the simulation and assessments demonstrated an increase in knowledge after the simulations. SUMMARY: TOC simulations enhance students' understanding of the significant impact that pharmacists have in ensuring continuity of care as members of an interdisciplinary team.

Anticholinergic burden: clinical implications for seniors and strategies for clinicians.

OBJECTIVE: To review the current literature assessing the risks associated with the use of anticholinergic (AC) medications in older adults and to provide recommendations for pharmacists to incorporate the evaluation of AC burden as a component of a medication therapy management program for older adults. DATA SOURCES: A MEDLINE/PubMed search was conducted from January 1990 to July 2011 using the terms anticholinergic, antimuscarinic, geriatric, aged, and elderly. References cited in studies and reviews identified in this search were also evaluated. Articles published in languages other than English or conducted in nonhuman species were not evaluated. STUDY SELECTION: Studies and reviews were included if they evaluated adverse events associated with the use of AC medications in the older adult population. DATA EXTRACTION: Data were extracted by the method of independent extraction by multiple observers based on their selection of sections. DATA SYNTHESIS: The review presents evidence that AC medications are associated with negative outcomes in older adults and the importance of health care provider interventions to avoid these consequences. CONCLUSION: AC burden is associated with adverse drug events and negative health outcomes in older adults. Health care providers should carefully assess the risks versus benefits of using medications with AC properties to minimize AC burden and prevent adverse outcomes in this vulnerable patient population. AC burden should be considered as acomponent of a medication therapy management program for seniors.

Cdc37/Hsp90 protein complex disruption triggers an autophagic clearance cascade for TDP-43 protein.

The RNA-binding protein, trans-active response DNA-binding protein 43 (TDP-43), is normally found in the nucleus, but in amyotrophic lateral sclerosis, frontal temporal dementia, and some cases of Alzheimer disease it is cleaved and mislocalized to the cytosol, leading to accumulation. The mechanisms contributing to this are largely unknown. Here, we show that part of the normal clearance cascade for TDP-43 involves the Cdc37/Hsp90 complex. An Hsp90 inhibitor that disrupts the Cdc37/Hsp90 complex reduced TDP-43 levels to a greater extent than a standard Hsp90 ATPase inhibitor. When Cdc37 was depleted, TDP-43 underwent proteolytic clearance that was dependent on nuclear retrotranslocation and autophagic uptake. Accumulation of the microtubule-associated protein tau prevented the clearance of cleaved TDP-43, but not its production. This caused cleaved TDP-43 to accumulate, a feature observed in the brain of persons with Alzheimer disease. Clearance of cleaved TDP-43 was also prevented by knockdown of the autophagic inducer beclin1. Thus, in cells where TDP-43 clearance is normally needed, a system that employs manipulation of the Hsp90 complex and autophagy exists. But when tau accumulation is occurring, cleaved TDP-43 can no longer be cleared, perhaps explaining the emergence of these co-pathologies.

Alcohol, medications, and the older adult.

Late-onset alcoholism is a common occurrence in older adults and may be a consequence of life-changing events such as retirement, declining health, loss of independence, or loss of a loved one. Alcohol use and misuse often go unrecognized. Alcohol use can cause significant drug interactions and exacerbate underlying disease. Because of physiologic changes in older adults, alcohol pharmacokinetics and pharmacodynamics may be altered and contribute to adverse alcohol-induced clinical consequences. We report on an elderly man who may have had unrecognized alcohol-induced drug interactions, falling, and exacerbation of heart failure. Following a fall, he was admitted to the hospital. After discharge, the man and his wife relocated to an assisted living facility and he abstained from alcohol. Four months later the man received a prescription for a glass of wine or two with dinner; one week later after two glasses of wine, a dose of lorazepam was given. Later that evening the patient fell and suffered a subdural hematoma. The effects of alcohol in older adults are discussed.

A new anti-depressive strategy for the elderly: ablation of FKBP5/FKBP51.

The gene FKBP5 codes for FKBP51, a co-chaperone protein of the Hsp90 complex that increases with age. Through its association with Hsp90, FKBP51 regulates the glucocorticoid receptor (GR). Single nucleotide polymorphisms (SNPs) in the FKBP5 gene associate with increased recurrence of depressive episodes, increased susceptibility to post-traumatic stress disorder, bipolar disorder, attempt of suicide, and major depressive disorder in HIV patients. Variation in one of these SNPs correlates with increased levels of FKBP51. FKBP51 is also increased in HIV patients. Moreover, increases in FKBP51 in the amygdala produce an anxiety phenotype in mice. Therefore, we tested the behavioral consequences of FKBP5 deletion in aged mice. Similar to that of naïve animals treated with classical antidepressants FKBP5-/- mice showed antidepressant behavior without affecting cognition and other basic motor functions. Reduced corticosterone levels following stress accompanied these observed effects on depression. Age-dependent anxiety was also modulated by FKBP5 deletion. Therefore, drug discovery efforts focused on depleting FKBP51 levels may yield novel antidepressant therapies.

The 3 D's of geriatric psychiatry: depression, delirium, and dementia.

A Caucasian female octogenarian with multiple medical problems was admitted to the inpatient geriatric psychiatry unit with intermittent altered mental status and decline in memory. She had been hospitalized four times in the previous three months. She was admitted on more than 10 medications and received more than 20 different medications in this time period. It was determined that she had delirium concurrent with dementia and/or depression. During her hospital stay a urinary tract infection (UTI) was treated, her anticholinergic medications were minimized, and her digoxin dose was adjusted. As her mental status cleared, a workup was completed to differentiate between dementia and depression. She was initially treated with memantine, but as time progressed it became more evident she was experiencing depression and a "pseudodementia," which was treated with sertraline. Her Mini-Mental State Examination returned to 29/30 (her score previously was 26/29). This case demonstrates the complexity of treating an elder individual and the importance of differentiating among delirium, depression, and dementia. The pharmacy team played an active role in medication reconciliation. Additionally, they worked with the medical team to minimize her potentially harmful medications and optimize the treatment of her UTI and depression.

Comparison of two drug-burden computational procedures applied to anticholinergic drugs.

Two computational procedures for estimating continuous drug-burden scores are compared, using a simulation study based on a sample of patients exposed to anticholinergic medications. Both procedures seek to quantify the medication burden to overcome the limitations of a binary classification of exposure. An artificial neural network procedure renders better statistical properties than a linear weighted score, even when both scores are correlated and are viable alternatives to binary classification.