Using a Polypharmacy Simulation Exercise to Increase Empathy in Pharmacy Students.

Objective. To assess whether the Jellybean Polypharmacy Simulation Exercise (JPSE) improved empathy in pharmacy students. Methods. The JPSE was given to all third-professional year pharmacy students in a required Special Populations course with pre- and post-scores on the Kiersma-Chen Empathy Scale (KCES) assessed, and open-ended questions on lessons learned from the exercise. Results. Pharmacy students showed a statistically significant increase in KCES scores after completing the JPSE. Open-ended question responses reflected personal growth and appreciation for patients managing difficult medication regimens. Conclusion. This polypharmacy simulation showed the ability to increase empathy in pharmacy students, as well as mimic a realistic experience in managing a multi-drug, multi-dose medication regimen.

Visual hallucinations treated with the reinitiation of memantine in a patient with Lewy body dementia.

OBJECTIVE: To report on a patient with Lewy body dementia who developed worsening of hallucinations with memantine withdrawal and significant improvement with reinitiation of the drug. CASE SUMMARY: A 78-year-old man presented to a geriatric psychiatry clinic in March 2011. The patient had experienced gradual memory loss since 2007 and was diagnosed with dementia with Lewy bodies (DLB) in 2009. His medication regimen included donepezil and memantine; his cognitive and functional status appeared stable. Occasional mild visual hallucinations occurred but were not concerning to the patient or his wife. The patient did well to July 2011, when memantine became restricted within the health care institution; memantine was therefore tapered to discontinuation. From July to September 2011, the patient's cognition and function appeared to decline significantly. He also began experiencing severe visual hallucinations daily. Memantine was reinitiated in September 2011 and, within days, the patient was free of hallucinations. By November 2011, his cognition and function were noted to have improved to previous status, and hallucinations were rare. DISCUSSION: Three small randomized studies and 4 case reports were found addressing the use of memantine for DLB. Both improvement and worsening of hallucinations were noted with memantine use in the case reports, but the studies showed only a small benefit in cognition. However, cognitive and psychiatric symptoms worsened when memantine was discontinued. One study found that Neuropsychiatric-Inventory scores and hallucination scores improved significantly for patients taking memantine. CONCLUSIONS: The literature investigating the use of memantine for the psychiatric symptoms of DLB is limited but there are data noting results similar to what we observed in our patient when his memantine was discontinued and reinitiated.

Geriatric primer - common geriatric syndromes and special problems.

Geriatric syndromes are common problems that affect older adults. They are often thought of as causes of morbidity in one or more functional domains, but they can simultaneously be a consequence of morbidity as well. This primer will cover 12 problems commonly considered to be geriatric syndromes and highlight the potential for outcomes in one area to affect those in another. The syndromes included are: losses in activities of daily living, cognitive dysfunction, delirium versus dementia, depression, dizziness, osteoporosis, falls, sensory loss, nutrition and weight loss, pain, substance abuse, urinary incontinence, and constipation. Each syndrome is briefly discussed, followed by strategies for assessment and intervention by the pharmacist in a community setting.

Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly.

A rising concern among clinicians is treatment of unplanned weight loss in the elderly, especially given the predicted growth of this population over the next few decades. Unexpected weight loss in the geriatric patient worsens overall health outcomes. A variety of pharmacotherapeutic options are available for treatment; however, evidence underlying their use is limited, and none has gained approval from the United States Food and Drug Administration for this indication. At present, no guidelines support the choice of one agent over another. Although several drug interventions have been employed for this problem, megestrol acetate and mirtazapine are becoming increasingly used for appetite stimulation. These drugs represent two feasible options for geriatric patients because of their generally favorable adverse-effect profiles and few drug interactions, but they are often misused. In a comprehensive search of the MEDLINE and International Pharmaceutical Abstracts databases, we identified all published reports on the use of megestrol acetate or mirtazapine for the treatment of weight loss and on any adverse events associated with these drugs. Special emphasis was placed on trials performed in an elderly population. Results were conflicting, most likely because of differing study designs and small numbers of patients. Megestrol acetate and mirtazapine appear to be effective for appetite stimulation and weight gain in some settings. However, applicability of the data to elderly individuals is unclear, and adverse events reported in a few of the trials and in case reports were not benign. Therefore, the use of megestrol acetate or mirtazapine for weight loss should be thoroughly evaluated on an individual basis. Pharmacotherapy should be used only after all underlying causes of weight loss are assessed and treated.

Propoxyphene prescribing among populations older and younger than age 65 in a tertiary care hospital.

OBJECTIVE: To evaluate the proportion of patients aged 65 years and older who are prescribed propoxyphene (PP) versus those aged 65 and younger. DESIGN: Retrospective cross-sectional study. SETTING: Tertiary care facility. PARTICIPANTS: Adult patients admitted to the hospital between January 1, 2005, and June 30, 2005, and prescribed either hydrocodone (HC) or PP. MAIN OUTCOME MEASURE: The primary outcome measure was the proportion of PP orders prescribed for patients older versus younger than age 65. The secondary outcomes were to identify other variables occurring in higher proportions among patients who were prescribed PP versus HC. RESULTS: Of the 7,910 patients reviewed, 7,295 patients 92.2% were prescribed HC and 615 (7.8%) were prescribed PP. In a random sample of 1,065 patients, the prescribing pattern of PP for subjects > or =65 (221/615, 35.9%), was significantly higher than for HC (128/450, 28.4%), P = 0.0122. In a random selection of the larger sample, there were 44/108 (40.7%) in the PP group and 22/120 subjects (18.3%) > or =65 in the HC group (P = 0.0003). Among PP users, there was a higher percentage of females (P = 0.0150), more subjects with narcotic allergies (P < 0.0001), and more subjects with a history of fractures (P = 0.0232). CONCLUSIONS: Compared with nationally reported data, the rate of PP prescribing is relatively low. However, despite the recommendation to avoid the use of PP in elderly patients, its use occurs in a higher proportion of patients age 65 years or older than in younger patients. Studies evaluating the prescribing rates of potentially inappropriate medications should be put in context by comparing reported data with that of a younger cohort.

Screening tests for intended medication adherence among the elderly.

BACKGROUND: Medication nonadherence is increasingly recognized as a cause of preventable adverse events, hospitalizations, and poor healthcare outcomes. While comprehensive medication adherence assessment for the elderly is likely to identify and prevent drug-related problems, it is time consuming for patient and healthcare providers alike. OBJECTIVE: To identify screening tools to predict elderly patients' intended medication adherence that are suitable for primary-care settings and community pharmacies. METHODS: This study evaluated 57 English-speaking persons aged 65 years and older who were from diverse socioeconomic backgrounds. Intended adherence was quantified, and the relationships to demographic, medical history, socioeconomic, and literacy variables were determined. RESULTS: In a multivariate analysis with the composite MedTake Test (a quantitative measure of each subject's intent to adhere to prescribed oral medications) as the dependent variable, independent predictors of intended adherence included: age, car ownership in the last 10 years, receipt of food assistance in the last 10 years, number of over-the-counter (OTC) medicines, and REALM (Rapid Estimate of Adult Literacy in Medicine). The strongest predictor was the REALM word-recognition pronunciation test (beta = 0.666; R2 = 0.271; p < 0.001). CONCLUSIONS: We observed that the REALM word-recognition pronunciation test, along with age, number of OTC drugs, and 2 socioeconomic questions, predicted the intent of seniors to correctly take their own prescribed oral medications.

Implications of rosiglitazone and pioglitazone on cardiovascular risk in patients with type 2 diabetes mellitus.

Clinical data suggest that thiazolidinediones--specifically, rosiglitazone and pioglitazone--may improve cardiovascular risk factors through multiple mechanisms. Low insulin sensitivity has been described as an independent risk factor for coronary artery disease and cerebrovascular disease. Patients with insulin resistance often have several known risk factors, such as obesity, dyslipidemia, and hypertension. Other emerging risk factors may be prevalent in patients with insulin resistance, such as hyperinsulinemia, elevated C-reactive protein, elevated plasminogen activator inhibitor levels, and small, dense, low-density lipoproteins. The only available drug class that primarily targets insulin resistance is the thiazolidinediones. These drugs have shown efficacy in affecting surrogate markers of cardiovascular risk in patients with diabetes mellitus. Alterations in these risk factors are likely due to their effects on improving insulin sensitivity and/or glycemic control. Trials to assess whether thiazolidinediones actually reduce cardiovascular outcomes are continuing.

Management of age-related osteoporosis and prevention of associated fractures.

Osteoporosis and related fractures are a significant concern for the global community. As the population continues to age, morbidity and mortality from fractures due to low bone mineral density (BMD) will likely continue to increase. Efforts should be made to screen those at risk for osteoporosis, identify and address various risk factors for falls and associated fractures, ensure adequate calcium and vitamin D intake, and institute pharmacological therapy to increase BMD when indicated. Agents which increase BMD and have been shown to decrease fractures, particularly at the hip, should be considered preferentially over those for which only BMD data are available. Drugs which have been shown to decrease the risk of age-related osteoporotic fractures include oral bisphosphonates (alendronate, ibandronate, and risedronate), intranasal calcitonin, estrogen receptor stimulators (eg, estrogen, selective estrogen receptor modulators [raloxifene]), parathyroid hormone (teriparatide), sodium fluoride, and strontium ranelate. Data are beginning to emerge supporting various combination therapies (eg, bisphosphonate plus an estrogen receptor stimulator), though more data are needed to identify combinations which are most effective and confer added fracture protection. In addition, further research is needed to identify ideal regimens in special populations such as nursing home patients and men.

Antipsychotic dose-sparing effect with addition of memantine.

OBJECTIVE: To describe a case of an antipsychotic-sparing effect achieved after the addition of memantine to the regimen of a patient with severe Alzheimer's disease and aggressive behavioral disturbances. CASE SUMMARY: A 78-year-old white man with severe Alzheimer's disease was receiving risperidone 2 mg 3 times daily for persistent aggressive and dangerous behavioral disturbances. Memantine was initiated, and the dose was titrated to 10 mg twice daily. The patient's response included improvement in functional status and resolution of problematic behaviors, allowing repeated reduction of the risperidone dose and ultimate discontinuation. DISCUSSION: Antipsychotics are often employed to treat behavioral disturbances for patients with Alzheimer's disease; however, the adverse effect potential of these agents remains a significant concern. Adjunctive medications that maintain or improve behavioral symptoms yet allow an antipsychotic-sparing effect are attractive. Such experiences have previously been described with other drug classes, but clinical experience is evolving with memantine. For this patient, the effect of this agent on behavioral symptoms and risperidone requirements is one example of such an antipsychotic-sparing effect. CONCLUSIONS: Response to memantine therapy may include behavioral improvements allowing a dose-sparing effect of antipsychotic medication. Changes in psychoactive drug burden may be a valuable surrogate marker of memantine's effects on behavior.

Adverse reaction to a dietary supplement in an elderly patient.

OBJECTIVE: To describe the case of an elderly patient who experienced hepatic enzyme elevations and symptoms of hepatitis associated with the administration of a dietary supplement. CASE SUMMARY: A 92-year-old white woman with no history of hepatic disease developed jaundice and increased confusion associated with increased hepatic enzymes. The hepatitis panel, abdominal ultrasound, and antinuclear antibody screen indicated no abnormalities. A drug regimen review revealed that the patient was receiving a dietary supplement, Nutrilite Double X Multivitamin-Multimineral. Following discontinuation of the supplement, the patient's symptoms resolved and the hepatic enzymes decreased or returned to the reference range at evaluations occurring 1 week and 1 month after intervention. An objective causality assessment revealed this to be a probable adverse drug event. DISCUSSION: While the association of certain herbal preparations with hepatotoxicity has been demonstrated, the potential for this adverse effect is easily overlooked. In this patient, infectious or autoimmune causes of acute hepatitis were ruled out, and drug-induced causes were considered. The resolution of symptoms and laboratory values following discontinuation of the supplement support a relationship between the dietary supplement and this episode of hepatitis. CONCLUSIONS: Our case indicates that there was a probable relationship between the dietary supplement Nutrilite Double X Multivitamin-Multimineral and the development of acute hepatitis. Due to the multi-ingredient formulation of the product, as well as lack of data describing manufacturing procedures, it is difficult to determine which component may be associated with this effect. Over-the-counter supplements should be considered as a part of the differential diagnosis in patients presenting with increased liver enzymes and related symptoms.

Individualized drug use assessment in the elderly.

STUDY OBJECTIVE: To quantify how seniors' ability to take oral prescription drugs safely may correlate with age, sex, socioeconomic status, education, cognitive impairment, depression, and drug self-management. DESIGN: Cross-sectional study SETTING: Three retirement communities and an adult day care center. PATIENTS: Fifty-seven elderly individuals (mean age 79.49 +/- 7.26 yrs; mean education 11.33 +/- 3.8 yrs; 72% women). INTERVENTION: After completing a comprehensive medical history, and with drug vials and pillboxes available for consultation, each subject described how he or she was taking prescribed oral drugs. MEASUREMENTS AND MAIN RESULTS: The MedTake test evaluated dosage, indication, food or water coingestion, and regimen. For each agent, the test was scored as percentage of correct actions, equally weighted, and compared with label directions or self-expressed physician changes. A composite MedTake test score (0-100%) summarized a subject's overall ability to take their drug(s) safely A follow-up qualitative assessment by a single pharmacist assigned each agent to one of four potential risk categories: correct use, partial correct use without potential clinical significance, partial correct use with potential clinical significance, or incorrect use with high potential of clinical significance. Most subjects (80%) managed their own drug therapy; 70% used reminder systems (calendar, pillbox). The number of medical conditions and prescription drugs was 6.11 +/- 4.2 and 5.88 +/- 3.44, respectively. Of 325 agents, correct dosage was reported for 94% (306), correct indication for 95% (309), correct coingestion with food or water for 97% (314), and correct regimen for 89% (288). The composite MedTake test score was 88.5 +/- 21.3%. The multivariate model, with that score as the dependent variable, adjusted for age and sex, used Mini-Mental State Examination (p = 0.002) and Medicaid assistance within 10 years (p = 0.021) as significant factors. The most frequent problem was underdosing of cardiovascular drugs. CONCLUSION: Seniors' ability to take oral prescription drugs safely was affected by cognitive function and socioeconomic status. Although the MedTake test helped identify some problems with therapy adherence, a pharmacist's follow-up evaluation of comprehensive medical and drug histories identified additional potentially clinically significant problems in 20% of subjects.