Statins for the primary prevention of cardiovascular disease in the elderly.

OBJECTIVE: The objective is to review the evidence evaluating the efficacy of statin therapy for primary prevention of cardiovascular (CV) disease in the elderly. DATA SOURCES: A literature search of MEDLINE and PubMed (1966-January 2013) using the terms HMG-CoA reductase inhibitor, statin, primary prevention, elderly, and geriatrics was performed. The search was limited to clinical trials, meta-analyses, and subanalyses, including primary prevention patients. Bibliographies of selected articles were examined to identify additional clinical trials. STUDY SELECTION: Fourteen clinical trials, subanalyses, and meta-analyses were reviewed. A total of seven clinical trials and subanalyses evaluating statin therapy versus placebo in the elderly primary prevention patients with a primary endpoint of hard coronary heart disease were included. DATA EXTRACTION: Data collected from the clinical trials and subanalyses included number of elderly patients randomized, therapy, duration of follow-up, and the incidence of coronary events. DATA SYNTHESIS: The average annual rates of first CV event increases as patients age. There is strong evidence that supports the use of statins for secondary prevention; although primary prevention, specifically in the elderly, is less defined. This paper reviews the literature specifically for primary prevention, for which the results have shown a trend toward decreased first occurrence of coronary heart disease with statin therapy in elderly patients. CONCLUSION: Statin therapy should be considered as a primary prevention therapy against coronary disease for elderly patients. Evidence-based clinical benefits are seen in this patient population. However, clinical judgment and consideration of comorbidities that may impact life expectancy should be assessed to determine appropriateness for individual patients.

Unnecessary lipid-lowering drugs in an outpatient geriatric clinic.

OBJECTIVES: Identify the number of patients in the University of Colorado Seniors Clinic who were prescribed a nonstatin lipid-lowering therapy and describe a pharmacist intervention that can reduce the unnecessary use of these agents. SETTING: Outpatient geriatrics clinic in a university health system. PRACTICE DESCRIPTION: The University of Colorado Seniors Clinic provides outpatient care for ambulatory patients 75 years of age or older. In 2012, there were 2,000 active patients, with 7,000 clinic visits. PRACTICE INNOVATION: All patients prescribed extended-release niacin, ezetimibe, fenofibrate, gemfibrozil, or prescription omega-3-acid ethyl esters were identified. Extended-release niacin, ezetimibe, fenofibrate, and gemfibrozil were deemed necessary if the patient was intolerant to statin therapy or could not attain the cholesterol goal with the maximum tolerated dose of a statin. Fenofibrate, gemfibrozil, and prescription omega-3-acid ethyl esters were considered necessary if the patient had a history of triglycerides above 500 mg/dL. If a pharmacist deemed the medication unnecessary, a note was placed in the medical record and discussed face-to-face with the provider. MAIN OUTCOME MEASURE(S): The number of patients and types of drugs that were prescribed and discontinued; the cost savings to the health system. RESULTS: Fifty-five patients were prescribed a potentially unnecessary lipid-lowering drug. Twenty-three drugs were discontinued, for an estimated $38,660.40 in cost savings. CONCLUSIONS: A low percentage of patients were prescribed a nonstatin lipid-lowering agent in this population. However, more than half were deemed unnecessary and were stopped, resulting in significant savings and health benefits. Applying this on a larger scale could result in significant savings and improved health.

Evaluation of type 2 diabetes mellitus medication management and control in older adults.

OBJECTIVES: The primary aims of this study were to characterize glycemic control and pharmacologic management in older patients and to compare glycemic control and pharmacological management in patients 65 to 79 years of age ("young-old") with those 80 to 89 years of age ("old-old"). We hypothesized that patients 80 to 89 years of age would be prescribed fewer medications and would have higher A1c values compared with younger patients. DESIGN: Retrospective medical record review. SETTING: This study was conducted in outpatient clinics within a university hospital setting. PATIENTS, PARTICIPANTS: This study included 400 adults 65 to 89 years of age with a diagnosis of type 2 diabetes mellitus and at least one A1c measurement over 12 months. MAIN OUTCOME MEASURES: A1c measurements and diabetes mellitus medications were assessed in these patients. RESULTS: The overall mean A1c was similar in the young-old compared with the old-old (7.1 ± 1.1% vs. 7.0 ± 1.1%; P = NS). There was no difference between groups for any of the A1c ranges studied. Fewer diabetes medications were prescribed in the old-old compared with the young-old (P = 0.003). In the young-old compared with the old-old, metformin (51.0% vs. 33.0%; P < 0.01), glucagon-like peptide-1 agonists (6.7% vs. 0%; P < 0.01), insulin glargine/detemir (24.7% vs. 13.0%; P < 0.05), and short-acting insulin (15.0% vs. 7.0%; P < 0.05) were more frequently prescribed. CONCLUSION: Our results indicate that glycemic control was similar between the young-old and old-old. However, the old-old required fewer diabetic medications for this same level of glycemic control.

Inhaled anticholinergic agents and acute urinary retention in men with lower urinary tract symptoms or benign prostatic hyperplasia.

OBJECTIVE: To assess the risk of acute urinary retention with the use of inhaled anticholinergic agents in men with lower urinary tract symptoms (LUTS) or benign prostatic hyperplasia (BPH). DATA SOURCES: A literature search was performed with MEDLINE via PubMed from 1967 through May 2012 using the terms inhaled anticholinergics, urinary retention, benign prostatic hyperplasia, lower urinary tract symptoms, tiotropium, and ipratropium. In addition, references from reviewed publications were identified and official labeling was obtained from the manufacturers' Web sites. STUDY SELECTION AND DATA EXTRACTION: Only English-language publications were included. Randomized controlled trial data, observational studies, case reports, package labeling, and commentaries regarding men with BPH/LUTS using inhaled anticholinergic agents and the associated development of urinary retention were reviewed. DATA SYNTHESIS: Two case reports; 1 prospective, open-label, single-arm study; and 2 nested case-control studies evaluated or described the use of inhaled anticholinergic agents and the development of acute urinary retention in men with BPH/LUTS. Taken together, the available data demonstrate that treatment with inhaled anticholinergic agents is associated with acute urinary retention in men with preexisting LUTS or BPH. CONCLUSIONS: Men with LUTS or BPH who are treated with inhaled anticholinergic agents may develop acute urinary retention, but this cannot be quantified based on the limited information available. Inhaled anticholinergic agents should be used when indicated in men with LUTS or BPH, but close monitoring and patient education should be implemented.

Histamine-1 receptor antagonism for treatment of insomnia.

OBJECTIVES: To evaluate the literature regarding the use of histamine-1 (H(1)) receptor antagonists and to describe their role in the treatment of insomnia in adult patients, including the elderly. DATA SOURCES: Literature was identified via PubMed and Medline through April 1, 2012, using the search terms insomnia and sleep, each individually combined with histamine antagonist, tricyclic antidepressant, trazodone, mirtazapine, doxepin, amitriptyline, nortriptyline, trimipramine, doxylamine, diphenhydramine, and antihistamine. STUDY SELECTION AND DATA EXTRACTION: Data included randomized double-blind trials that statistically evaluated H(1) receptor antagonist treatment in patients with insomnia compared with a placebo control or Food and Drug Administration-approved insomnia treatment. Trials selected evaluated sleep latency, wake after sleep onset, total sleep time, number of awakenings, and/or sleep efficiency in a subjective or objective manner. A total of 65 trials were evaluated, and 16 met inclusion criteria. DATA SYNTHESIS: With the exception of low-dose doxepin (Silenor-Somaxon), trials evaluating the clinical effectiveness of H(1) receptor antagonists show mixed results and are limited by sample size and generalizability. Large, randomized, appropriately controlled trials are lacking, making it difficult to define the safety and efficacy of these agents. In contrast, low-dose doxepin has been shown to provide consistent sleep benefit compared with placebo. CONCLUSION: Over-the-counter antihistamines may have a role for short-term insomnia treatment in younger adults, but tolerance develops rapidly. Mirtazapine should not be used solely for the treatment of insomnia. Sedating antidepressants can be considered after failure of first-line insomnia treatments. Patients taking these agents chronically should be evaluated for continued efficacy and potential harm. Low-dose doxepin may have a unique role in the treatment of insomnia in elderly patients given its tolerability, documented efficacy, and lack of important adverse effects.

Medication management: a case of brown bag-identified medication hoarding.

A 91-year-old woman living independently in the community presented along with her son for a medication therapy management (MTM) appointment with the clinical pharmacist at the University of Colorado Hospital Seniors Clinic. The purpose of the visit was to review the patient's medications, perform medication reconciliation, and identify ways to increase proper medication management. As requested for the MTM appointment, the patient and her son brought in several large bags of her over-the-counter (OTC) and prescription medications from her home, including those that she was not currently taking. The clinical pharmacist reviewed the medications and found multiple instances of duplicate therapies, nonadherence, discrepancies in her medication regimen, cost concerns, and other drug-therapy problems. In addition, the pharmacist's evaluation showed that the patient had been hoarding more than 100 medications, which increased her risk for drug-related problems. Most of the OTC and some prescription medications were voluntarily removed from the patient's possession to reduce the likelihood of potential overuse of medications.The pharmacist educated the patient and her son regarding her updated medication list and how to properly manage her medications. Finally, the patient's son volunteered to help his mother with medication management or hire someone to assist her. This case demonstrates the usefulness of requesting all medications-including OTC and prescription, active and inactive medications-be brought to the MTM appointment.The case also supports the need for family support for older adults struggling with managing polypharmacy.

Combination antiplatelet agents for secondary prevention of ischemic stroke.

Stroke is a leading cause of death and the primary cause of serious, long-term disability in the United States. Joint guidelines from the American Heart Association (AHA) and American Stroke Association (ASA), as well as recent guidelines from the Eighth American College of Chest Physicians (ACCP) Conference on Antithrombotic and Antiplatelet Therapy, recommend aspirin, clopidogrel, or extended-release dipyridamole plus aspirin as acceptable first-line options for secondary prevention of ischemic events in patients with a history of ischemic stroke or transient ischemic attack (TIA). The ACCP strongly recommends the combination of extended-release dipyridamole plus aspirin over aspirin monotherapy (highest level of evidence) and suggests clopidogrel monotherapy over aspirin monotherapy (lower level of evidence). The AHA-ASA guidelines suggest that either extended-release dipyridamole plus aspirin or clopidogrel monotherapy should be used over aspirin monotherapy. Both guidelines recommend avoiding the combination of clopidogrel and aspirin for most patients with previous stroke or TIA. Results from recent trials evaluating combination antiplatelet therapy have been published that enhance the AHA-ASA recommendations and provide the foundation for the updated ACCP guideline. To identify pertinent combination antiplatelet trials, a MEDLINE search of the literature from 1967-2007 was performed. Two trials were identified--the European-Australasian Stroke Prevention in Reversible Ischemia Trial (ESPRIT) and Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA). The ESPRIT compared aspirin monotherapy with the combination of aspirin plus extended-release dipyridamole for prevention of secondary ischemic events in patients with a history of TIA or minor stroke. The CHARISMA trial compared aspirin plus clopidogrel with aspirin alone in a population at high risk for atherothrombotic events using the composite outcome of myocardial infarction, stroke, and death from cardiovascular causes. Data from ESPRIT add to evidence that the combination of aspirin plus extended-release dipyridamole is superior to aspirin alone. The findings of the CHARISMA trial reinforce recommendations from both AHA-ASA and ACCP that the combination of aspirin and clopidogrel be reserved for special populations requiring this antiplatelet combination (e.g., those who have had coronary artery stenting).

Vitamin D intervention by pharmacists in geriatric outpatients.

OBJECTIVES: To develop a pharmacist-provided educational intervention that instructs participants to consume 1,200 IU vitamin D daily and to evaluate its effect on serum 25-hydroxyvitamin D (vitamin D) concentrations and self-reported daily vitamin D intake in geriatric outpatients with insufficient vitamin D. DESIGN: Randomized controlled trial. SETTING: University-affiliated geriatric clinic, December 2005 to May 2006. PATIENTS: 80 participants aged 65 to 89 years. INTERVENTION: Participants with insufficient vitamin D (12-31 ng/mL) were randomized to receive either the educational intervention (n = 23) or no intervention (n = 22). MAIN OUTCOME MEASURES: Difference in change from baseline to 12 weeks in vitamin D concentrations and self-reported daily vitamin D intake between groups. RESULTS: At 12 weeks, vitamin D concentrations in the educational intervention group (n = 22) increased from a mean (+/- SD) of 23.5 +/- 5.0 to 30.4 +/- 6.3 ng/mL. Vitamin D concentrations in the nonintervention group (n = 21) increased from 22.8 +/- 5.4 to 26.9 +/- 6.2 ng/mL. The difference between the groups at 12 weeks did not reach statistical significance (P = 0.07). However, 12 participants (55%) in the educational intervention group achieved sufficient vitamin D concentrations compared with only 5 participants (24%) in the nonintervention group (P = 0.04). Self-reported daily vitamin D intake increased by a mean of 647 IU/day in the educational intervention group and 67 IU/day in the nonintervention group. The difference in self-reported intake between groups at 12 weeks, controlling for baseline, was significant (P < 0.0001). Serum parathyroid hormone concentrations decreased significantly among those in the intervention group (P = 0.04). CONCLUSION: A pharmacist-developed and -administered vitamin D educational intervention increased the proportion of participants achieving sufficient vitamin D concentrations, increased the self-reported daily vitamin D intake, and lowered serum parathyroid hormone concentrations. However, it did not significantly increase the overall mean serum vitamin D concentration, compared with the control group. A daily recommendation of more than 1,200 IU vitamin D daily is likely necessary to ensure that all geriatric outpatients with insufficient vitamin D concentrations achieve the target of at least 32 ng/mL.

Blood pressure control rates measured in specialty vs primary care practices within a large integrated health system.

Blood pressure measurement is a diagnostic test and a key component of assessing and managing hypertension, a major contributor to cardiovascular risk. Based on real-world clinical observations within a large, university-based, accountable care organization, we sought to assess whether blood pressure control results varied by the assessment setting, primary care versus specialty. We studied the most recent outpatient measurement for patients with hypertension during the 2016 calendar year and categorized each as being performed in a primary care or specialty setting, and as being controlled (<140/90 mm Hg) or uncontrolled. Among the 86 512 patients identified, the 43 364 whose most recent blood pressure measurement was in a specialty setting were significantly less likely to be controlled compared to the 43 148 whose most recent measurement was in primary care (63% vs 68%, respectively, OR = 0.83 [0.80-0.85]). For the 27 955 patients who had measurements performed in both settings during the year, the control rates based upon their most recent specialty and primary care measurements were 63% and 71%, respectively (OR = 0.62, 0.60-0.65). For the subsets of patients whose measurements in each setting were within 30 or within seven days of each other, the odds of control in the specialty versus primary care setting were 0.63 (0.58-0.75) and 0.65 (0.57-0.75), respectively. Health systems should weigh the value of performing blood pressure measurement in specialty settings that do not manage this condition, taking into consideration the resources required to perform it and the potential negative consequences of inaccurate measurements.

Development and economic evaluation of a pharmacist-provided chronic care management service in an ambulatory care geriatrics clinic.

PURPOSE: The implementation and delivery of a pharmacist-led chronic care management (CCM) service in a geriatric primary care clinic are described. METHODS: A CCM service was provided March 1 through December 31, 2016, at the University of Colorado Hospital Seniors Clinic ("Seniors Clinic"). The electronic health record (EHR) team for the University of Colorado Health system developed a patient registry through EPIC Healthy Planet (Epic Systems Corp., Verona, WI) to identify patients at the Seniors Clinic eligible for CCM services. The EHR team constructed a note type and documentation template within the EHR to ensure documentation of all necessary components for billing and to allow individual clinical staff to document the time spent providing CCM care. RESULTS: Overall, 36 elderly patients enrolled in the pharmacist-provided CCM service over the 10 months. Clinical pharmacists spent a total of 156-849 minutes per month providing CCM services, with a mean outreach time of 45.4 minutes per patient. The clinical pharmacists submitted 95 claims, and all but 5 were paid. The total amount reimbursed from the health plans during the 10 months was $2,775.02. CONCLUSION: Medicare patients were successfully enrolled in a CCM service in a geriatrics primary care clinic led by clinical pharmacists and medical providers. The CCM services were more time-consuming than the allotted 20 minutes per patient per month with the CCM Current Procedural Terminology code used during this study.

Expansion of clinical pharmacist positions through sustainable funding.

PURPOSE: Expansion of clinical pharmacist positions through sustainable funding is described. SUMMARY: The University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences was awarded a 2-year program grant to establish an integrated clinical pharmacy program for underserved residents in family health centers in northeastern Colorado. The grant enabled the hiring of 2 bilingual, full-time, board-certified, postgraduate year 2-trained clinical pharmacists to initiate comprehensive clinical pharmacy services. Clinical pharmacy services for diabetes, hypertension, and dyslipidemia management were provided during direct patient care visits using collaborative drug therapy management protocols to facilitate comprehensive medication management. Initial visits lasted 1 hour, and follow-up visits lasted 30 minutes. In addition, clinical pharmacists provided point-of-care consultations for patients seeing other healthcare providers. All patient encounters and consultations were documented in the electronic health record. Success of the clinical pharmacy program was evaluated based on the achievement of goal blood pressure values, glycosylated hemoglobin values, and low-density-lipoprotein cholesterol levels. Pharmacists' involvement in patient care activities led to improvements in all of these clinical outcomes. This coincided with unique funding opportunities with regional accountable care organizations that sought to demonstrate improved patient care in an expansion population. As a result, 2 grant-funded clinical pharmacist positions in 2 community health clinics were converted into 4 faculty positions in 5 community health centers funded by regional accountable care organizations. CONCLUSION: Collaboration with accountable care organizations resulted in the successful funding of ambulatory care clinical pharmacy services. These services resulted in improved chronic disease control and provider satisfaction.

Prevalence of vitamin D insufficiency in elderly ambulatory outpatients in Denver, Colorado.

BACKGROUND: Vitamin D insufficiency is common in the elderly. However, previous studies have utilized 25-hydroxvvitamin D (25[OH]D) concentrations as low as <16 ng/mL for defining vitamin D insufficiency. Moreover, most of the studies have been conducted in European patients, in certain geographic areas of the United States, or in institutionalized elderly. OBJECTIVE: The goal of this study was to characterize vitamin D concentrations in ambulatory elderly living in metropolitan Denver, Colorado, utilizing 25(OH)D concentrations <32 ng/mL as the definition for vitamin D insufficiency. METHODS: Ambulatory older adults (aged 65-89 years) with clinic visits during December 2005 and January 2006 were enrolled. Serum concentrations of 25(OH)D, parathyroid hormone (PTH), calcium, phosphorus, creatinine, and albumin were measured; height and weight were also measured. Data regarding dietary and over-the-counter vitamin D intake were collected, as well as information on body mass index, history of osteoporosis, osteoporosis treatment, and history of falls and fractures. RESULTS: Eighty patients (mean [SD] age, 77.8 [5.3] years; age range, 66-89 years) completed the study; there were no dropouts. The majority of patients were white (88%) and female (68%). Fifty-nine (74%) were found to have vitamin D insufficiency. Mean total and over-the-counter vitamin D intake was significantly higher in sufficient (P < 0.01) and insufficient (P < 0.05) patients compared with deficient patients, but dietary intake did not differ significantly between groups. The majority of patients who were vitamin D insufficient consumed more than the recommended 400 to 600 IU/d of vitamin D. Obese patients were found to have significantly lower 25(OH)D concentrations (P < 0.001) and higher PTH concentrations (P = 0.04) than nonobese patients. CONCLUSIONS: Vitamin D insufficiency is prevalent in ambulatory, and especially obese, elderly living in Denver, Colorado, despite vitamin D intake consistent with national recommendations. Dietary intake of vitamin D appeared to be unreliable to prevent insufficiency. Based on our results, along with other published data, we feel that national recommendations for vitamin D intake in the elderly should be increased to at least 800 to 1000 IU/d of over-the-counter supplemental cholecalciferol.

Effect of an Advanced Pharmacy Practice Experience on Medication Therapy Management Services in a Centralized Retail Pharmacy Program.

BACKGROUND: Medication therapy management (MTM) delivery is increasingly important in managed care. Successful delivery positively affects patient health and improves Centers for Medicare & Medicaid Services star ratings, a measure of health plan quality. As MTM services continue to grow, there is an increased need for efficient and effective care models. The primary objectives of this project were to describe the delivery of MTM services by fourth-year Advanced Pharmacy Practice Experience (APPE) students in a centralized retail pharmacy system and to evaluate and quantify the clinical and financial contributions of the students. The secondary objective was to describe the engagement needed to complete comprehensive medication reviews (CMRs) and targeted interventions. PROGRAM DESCRIPTION: From May 2015 to December 2015, thirty-five APPE students from the University of Colorado Skaggs School of Pharmacy provided MTM services at Albertsons Companies using the OutcomesMTM and Mirixa platforms. Students delivered patient care services by phone at the central office and provided face-to-face visits at pharmacies in the region. With implementation of the MTM APPE in 2015, the team consisted of 2 MTM pharmacists and pharmacy students, as compared with 1 MTM pharmacist in 2014. The number of CMRs and targeted interventions completed and the estimated additional revenue generated during the 2015 time period were compared with those completed from May through December 2014. The patient and provider engagement needed to complete the CMRs and targeted interventions was summarized. OBSERVATIONS: 125 CMRs and 1,918 targeted interventions were billed in 2015, compared with 13 CMRs and 767 targeted interventions in 2014. An estimated $16,575-$49,272 of additional revenue was generated in 2015. To complete the interventions in 2015, the team engaged in 1,714 CMR opportunities and 4,686 targeted intervention opportunities. IMPLICATIONS/RECOMMENDATIONS: In this MTM rotation, students provided real-life care to patients, resulting in financial and clinical contributions. This model of education and care delivery can be replicated in the community pharmacy or managed care setting. APPE students are an important component of this model of care delivery, particularly when considering the level of patient engagement needed to complete MTM interventions. DISCLOSURES: No outside funding supported this research. The authors have no conflicts of interest to disclose related to this work. All authors contributed to study concept and design. Rodgers collected the data, and data interpretation was performed by Vande Griend, along with Rodgers and Nuffer. The manuscript was written and revised primarily by Vande Griend, along with Nuffer and Rodgers. This project was presented at the Pharmacy Quality Alliance Annual Meeting in Arlington, Virginia, in May 2016.

ACCP Clinical Pharmacist Competencies.

The purpose of the American College of Clinical Pharmacy (ACCP) is to advance human health by extending the frontiers of clinical pharmacy. Consistent with this mission and its core values, ACCP is committed to ensuring that clinical pharmacists possess the knowledge, skills, attitudes, and behaviors necessary to deliver comprehensive medication management (CMM) in team-based, direct patient care environments. These components form the basis for the core competencies of a clinical pharmacist and reflect the competencies of other direct patient care providers. This paper is an update to a previous ACCP document and includes the expectation that clinical pharmacists be competent in six essential domains: direct patient care, pharmacotherapy knowledge, systems-based care and population health, communication, professionalism, and continuing professional development. Although these domains align with the competencies of physician providers, they are specifically designed to better reflect the clinical pharmacy expertise required to provide CMM in patient-centered, team-based settings. Clinical pharmacists must be prepared to complete the education and training needed to achieve these competencies and must commit to ongoing efforts to maintain competence through ongoing professional development. Collaboration among stakeholders will be needed to ensure that these competencies guide clinical pharmacists' professional development and evaluation by educational institutions, postgraduate training programs, professional societies, and employers.

Assessment of blood pressure in patients with hypertension aged 60-79 years before and after the publication of the 2014 Eighth Joint National Committee report.

OBJECTIVES: In late 2013, the Joint National Committee (JNC 8) published hypertension treatment recommendations endorsing a goal blood pressure (BP) of < 150/90 mmHg starting at age 60 years. This was in contrast to other cardiovascular groups recommending age 80 years for this BP goal. This study examined mean BP in patients from age 60 years to 79 years with hypertension before and after publication of the JNC 8 recommendations. METHODS: This retrospective cohort study examined mean BP and number of antihypertensives for a period of 1 year before and after the release of the JNC 8 report. Patients aged 60-79 years with hypertension receiving care at a University of Colorado Hospital primary care clinic were included. Patients with diabetes, chronic kidney disease, or kidney transplant were excluded. A total of 150 BP measurements were included in each of the before and after time frames. The primary outcomes were change in mean BP and number of antihypertensives. RESULTS: A total of 171 patients met the criteria and were included in the study. Most had BPs in both the before and after time frames. Mean BP values were similar in the before and after groups (130.2/75.9 mmHg versus 131.5/76.6, respectively; p = 0.27/p = 0.46). Mean number of antihypertensives were similar in the before and after groups (1.95 versus 1.93, respectively; p = 0.79). CONCLUSIONS: Over 1 year at an academic health system, new recommendations from the JNC 8 did not affect mean BP or number of antihypertensives in older patients with hypertension. A similar investigation after more time or in patients with newly diagnosed hypertension may help determine the full impact.

Prioritization of patients for comprehensive medication review by a clinical pharmacist in family medicine.

BACKGROUND: This pilot study describes and evaluates the clinical pharmacy priority (CP2) score. We hypothesize that patients with high CP2 scores are more likely to receive a medication recommendation after comprehensive medication review (CMR) than patients with lower scores. Prioritization of patients for CMR by a clinical pharmacist in family medicine could enhance the provision of interprofessional care within the patient-centered medical home. METHODS: The CP2 score was developed collaboratively by the research team and is derived from 11 patient-specific factors extracted from the electronic health record. To evaluate the utility of the score, CMR was performed prospectively by a clinical pharmacist for patients with appointments between October 1 and December 31, 2012, at 2 University of Colorado family medicine clinics. RESULTS: CMR was performed for 1107 patient appointments. Of these, 101 were identified as having received a medication recommendation from the clinical pharmacist. For patients with a CP2 score of 0 to 2, 2 of 588 charts (0.3%) reviewed received a recommendation (level 1). The proportion increased to 37 of 358 (10.3%) for scores of 3 to 7 (level 2), 40 of 119 (33.6%) for scores of 8 to 10 (level 3), and 22 of 42 (52.4%) for scores of ≥11 (level 4). Compared with CP2 scores in level 1, patient appointments were more likely to receive a medication recommendation after CMR in level 2 (relative risk [RR], 30.4; 95% confidence interval [CI], 7.4-125.3), in level 3 (RR, 98.8; 95% CI, 24.2-403.3), and in level 4 (RR, 154; 95% CI, 37.5-632.8). CONCLUSIONS: Patients with higher CP2 scores were more likely to receive a medication recommendation after CMR by a clinical pharmacist than patients with lower scores. The CP2 score could be used by clinical pharmacists in family medicine to enhance the efficient and effective delivery of interprofessional care.

Quetiapine for insomnia: A review of the literature.

PURPOSE: The safety and efficacy of quetiapine for the treatment of insomnia in adults are reviewed. SUMMARY: Quetiapine was developed for the treatment of psychiatric disorders, but its antagonism of histamine H1- and serotonin type 2A receptors has the added effect of causing sedation. As such, quetiapine is widely used off-label as a treatment for insomnia. Due to quetiapine's potential adverse effects, guidelines for the treatment of insomnia have recommended the drug's use only in patients with specific comorbid psychiatric disorders. The use of quetiapine for the treatment of insomnia in the absence of comorbid conditions has been evaluated in only two clinical trials of 31 patients in total, and very few studies have evaluated quetiapine use in patients with insomnia and other comorbidities. No trials have been conducted comparing quetiapine with an active control (e.g., zolpidem); the data that exist compare quetiapine to a placebo or there is no comparison and all patients are treated with quetiapine. Very few studies have evaluated quetiapine's efficacy in the treatment of insomnia using sleep objective testing, another limitation of the available data on quetiapine. CONCLUSION: Robust studies evaluating the safety and efficacy of quetiapine for the treatment of insomnia are lacking. Given its limited efficacy data, its adverse-effect profile, and the availability of agents approved by the Food and Drug Administration for the treatment of insomnia, quetiapine's benefit in the treatment of insomnia has not been proven to outweigh potential risks, even in patients with a comorbid labeled indication for quetiapine.

Glycemic targets and medication limitations for type 2 diabetes mellitus in the older adult.

OBJECTIVE: To review the optimal management of type 2 diabetes mellitus (T2DM) in the older adult. DATA SOURCES: A PubMed search was completed to identify publications in the English language from 1947 to 2013 using combinations of the search terms: geriatrics, aged, diabetes mellitus, and type 2 diabetes mellitus. References of articles were also reviewed for inclusion if not identified in the PubMed search. STUDY SELECTION AND DATA EXTRACTION: Original studies, clinical reviews, and guidelines were identified and evaluated for clinical relevance. DATA SYNTHESIS: Although the number of older adults with T2DM is growing, evidence for the treatment of T2DM in this population is lacking. Barriers such as polypharmacy, comorbid conditions, economic limitations, cognitive impairment, and increased risk of hypoglycemia may limit optimal glycemic control in older adults. Several organizations provide recommendations for glycemic targets and recommend using standard glycemic goals in most healthy older adults. However, less stringent goals are necessary in certain older populations such as those patients with limited life expectancy and severe hypoglycemia. In general, glycemic goals should be individualized in older patients. Age-related pharmacokinetic and pharmacodynamic changes, comorbid conditions, adverse drug reactions, ease of medication administration, and cost of medications necessitate the need to individualize pharmacologic therapy. CONCLUSION: Glycemic targets and medication use for T2DM should be individualized in older adults.