Caregiver-Based Interventions to Optimize Medication Safety in Vulnerable Elderly Adults: A Systematic Evidence-Based Review.

OBJECTIVES: To study the effect of caregiver-focused interventions to support medication safety in older adults with chronic disease. DESIGN: Systematic review. SETTING: Studies published before January 31, 2017, searched using Ovid Medline, PubMed, EMBASE, Scopus, CINAHL, PsycINFO, and Google Scholar. PARTICIPANTS: Caregivers with or without a care recipient. MEASUREMENTS: Inclusion criteria: interventions focused on caregivers aiming to improve medication safety. Studies not focusing on older adults, not evaluating medication safety, failing to include caregivers, or without a comparison group were excluded. RESULTS: The initial search revealed 1,311 titles. Eight studies met inclusion criteria. The strategies used in randomized trials were a home-based medication review and adherence assessment by a clinical pharmacist (2 home visits 6-8 weeks apart, with pharmacist and physician meeting independently) that found no difference in nonelective hospital admissions (p=.8) but fewer medications (p=.03); a 19-minute educational DVD and an hour-long medication education and training that improved caregiver satisfaction (p<.04); a medication education and adherence intervention (2-3 home visits per care recipient and caregiver dyad over 8 weeks) that found no difference in knowledge, administration, or accessibility of medications (p=.29); and a collaborative case management program (16-month program of assessment, meeting, and monthly follow-up telephone calls) that reduced perceived caregiver burden (p=.03). Quasi-experimental trials included collaborative care transitional coaches, an outpatient collaborative care model, and education and training programs. Of these, educational interventions showed improvements in self-efficacy, confidence, and preparedness. The collaborative care intervention reduced rehospitalizations (p=.04) and improved quality-of-care outcomes. CONCLUSION: Although some interventions improved caregiver medication knowledge and self-efficacy, effects on clinical outcomes and healthcare use were insufficiently studied. Two studies implementing collaborative care models with medication management components showed potential for improvement in quality of clinical care and reductions in healthcare visits and warrant further study with respect to medication safety. J Am Geriatr Soc 66:2128-2135, 2018.

Initiation of cholinesterase inhibitors in an inpatient setting.

We examined initiation of cholinesterase inhibitors (ChEIs) to determine whether ChEIs were being newly prescribed without sufficient evaluation for dementia and/or delirium and to explore whether there are differences in outcomes, such as mortality, hospital readmission rates, and duration of hospitalization, between patients newly started on ChEI and those who continued such medications prior to admission. Patients hospitalized in fiscal year 2008 and prescribed ChEI were identified. We reviewed electronic medical records. Of 282 patients, 15.6% (44) were new-starts and 84.4% (238) were continuations. Median length of stay was 16 days in new-starts versus 6 days in continuations (P < .05). Of new-starts, 38.6% were also treated of infection. Chart review additionally suggested possible treatment of delirium by initiation of benzodiazepines and antipsychotics in 11.4% and 22.7% of new-starts, respectively. We observed a substantive practice of initiating ChEIs in hospitalized elderly patients at risk of delirium. Although there was no difference in the 30-day mortality or readmission rates, new-starts were more likely to have a longer hospital stay than continuation patients.

Incidence of cholinesterase inhibitor therapy initiation among hospitalized patients.

BACKGROUND: Initiation of cholinesterase inhibitor (ChEI) therapy for delirium during hospitalization is ineffective and may be associated with increased morbidity and mortality. OBJECTIVE: To describe the incidence of initiating ChEI therapy during hospitalization. DESIGN: A retrospective cross-sectional study. SETTING: A tertiary-care academic medical center. PATIENTS: Inpatient admissions from September 2010 through March 2011 with ChEI administration. INTERVENTION: None. MEASUREMENTS: Incidence of ChEI exposure, initiation of ChEI therapy, initiation of antipsychotics and benzodiazepines, infection, in-hospital mortality, and hospital length of stay. RESULTS: The incidence of adult admissions with ChEI exposure and ChEI initiation was 23.2 (95% confidence interval: 21.2-25.4) and 2 (95% confidence interval 1.5-2.8) per 1000 admissions, respectively. Of 476 admissions receiving ChEI, 9% (n = 42) initiated therapy during the hospital stay and 91% (n = 434) continued on previously started therapy. Patients initiated on ChEI therapy frequently had infection (20 of 42) and were commonly initiated on antipsychotics (14 of 42) and benzodiazepines (13 of 42). Patients were hospitalized for a median of 2 days (interquartile range, 1-4) before initiation of ChEI and were exposed to therapy for a median of 3 days (interquartile range, 2-6). Of the 41 patients discharged from the hospital, 90% (n = 37) had orders to continue the ChEI postdischarge. CONCLUSIONS: Despite a lack of evidence to support the practice, 9% of patients who received ChEI therapy were initiated during the inpatient setting. These patients were not routinely screened for delirium and frequently received treatments associated with delirium.

The implications of increasing age on erectile dysfunction.

Erectile dysfunction (ED) has long been correlated with psychological well-being. More recently, an understanding has developed of ED being, in some cases, a vascular condition of the penile artery. Given the narrowness of the penile artery, a small amount of atherosclerosis may result in ED before any other manifestations are evident, making ED a useful marker for other vascular conditions with potentially greater clinical implications. In light of this, possible underreporting of ED takes on added significance. A questionnaire regarding ED prevalence and management was distributed for self-administration to men in the waiting room of primary care clinics; the data were analyzed with a focus on the relationship between ED and age. The study had a remarkable response rate of >95%. The prevalence of ED in the ≥70-year age-group was 77%, compared with 61% in the 40- to 69-year age-group (p = .0001). ED correlated linearly with age (R(2) = .80, p < .0001). Among those who had ED, more than half had not discussed it with any provider; the likelihood of discussing ED did increase with the reported severity of symptoms (p < .0001). Older men had more severe ED than younger men (p < .0001). Furthermore, 72% of men with a history of ED were never treated. Younger men were more likely to be treated than older men (p = .004). Given the potential implications of underreporting ED, and the willingness of the men in this study to complete the questionnaire, further work may be merited on new models for ED assessment and follow-up.