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Many older adults experience some degree of cognitive impairment, an important risk factor for medication nonadherence. To prevent negative health outcomes secondary to medication nonadherence, identifying interventions that improve medication adherence for older adults with cognitive impairment is crucial. Other barriers to medication adherence include the structure of the health care system as well as socioeconomic and therapyrelated obstacles. The use of pharmacist-led and population-level interventions hold promise for providing optimal medication adherence for older adults with cognitive impairment.
Though older adults are more sensitive to the effects of medications than their younger counterparts, they are often excluded from manufacturer-based clinical studies. Practice-based research is a practical method to identify medication-related effects in older patients. This research also highlights the role of a pharmacist in improving care in this population. A single study rarely has strong enough evidence to change geriatric practice, unless it is a large-scale, multisite, randomized controlled trial that specifically targets older adults. It is important to design studies that may be used in systematic reviews or meta-analyses that build a stronger evidence base. Recent literature has documented a gap in advanced pharmacist training pertaining to research skills. In this paper, we hope to fill some of the educational gaps related to research in older adults. We define best practices when deciding on the type of study, inclusion and exclusion criteria, design of the intervention, how outcomes are measured, and how results are reported. Well-designed studies increase the pool of available data to further document the important role that pharmacists have in optimizing care of older patients.
OBJECTIVE: Provide an up-to-date review for health care providers regarding clinically significant food-drug interactions and summarize recommendations for optimal medication administration in older adults and long-term care patients. DATA SOURCES: A literature search was performed using MEDLINE, PUBMED, and IPA abstracts to locate relevant articles published between January 1982 and July 2017. DAILYMED was used to identify manufacturer-specific medication administration recommendations. STUDY SELECTION AND DATA EXTRACTION: Articles were reviewed for inclusion based on their relevance to this subject matter and the integrity of the information provided. Additionally, the package labeling of included products was reviewed. DATA SYNTHESIS: The current recommendations for specific medication administration with regard to food are summarized descriptively. CONCLUSION: Clinically significant food-drug interactions are common and have been reported with multiple classes of medications. However, there are a limited number of studies examining food-drug interactions, and the majority of recommendations are made by product-specific manufacturers. Pharmacists should be aware of common food-drug interactions in the community, assisted living, long-term care, subacute care, and hospital settings. To optimize medication therapy and improve therapeutic outcomes, it is important for pharmacists and other health care providers to identify agents with potential for food-drug interactions and to understand the clinical relevance of such interactions.
OBJECTIVE:To review and summarize studies on the changes in bone mineral density (BMD) and fracture risk following discontinuation of teriparatide therapy.DATA SOURCES:A search of PubMed (1966-May 2016) and International Pharmaceutical Abstracts (1970-May 2016) was conducted using the Medical Subject Headings terms teriparatide, osteoporosis, and withholding treatment. Free text searches included drug holiday, discontinuation, and drug discontinuation.STUDY SELECTION AND DATA EXTRACTION:These searches yielded 79 articles. There were 7 articles reviewed that addressed the effects of teriparatide discontinuation on markers of overall bone health and fracture risk.DATA SYNTHESIS:Teriparatide is a recombinant human parathyroid hormone that is indicated for a lifetime maximum of 24 months in the United States for the treatment of osteoporosis in men and women at high fracture risk. There is inconsistent evidence regarding retained skeletal integrity resulting from increased bone resorption. Study analyses have shown that female patients seem to have more reduction in BMD upon teriparatide discontinuation. Several studies evaluating teriparatide discontinuation were follow-up studies with small patient populations, limiting the generalizability and statistical rigor associated with assessing these outcomes. In addition, the majority of patients were receiving bisphosphonate therapy, and the true effect of discontinuing teriparatide remains unknown.CONCLUSION:Independent patient risk factors should be taken into consideration when weighing the risk-vs.-benefit of initiating and discontinuing teriparatide therapy. Additional randomized control trials should be conducted to determine long-term effects of discontinuing teriparatide in the presence and absence of other bone-strengthening agents.
OBJECTIVE: Review the clinical manifestations and treatment of primary Sjögren's syndrome. DATA SOURCES: Articles indexed in PubMed, Scopus, and the Cochrane Library in the past 10 years using the key words "Sjögren," "Sjögren's syndrome," "Sjögren's disease," and "Sjögren's syndrome AND treatment." Primary sources were used to locate additional resources. STUDY SELECTION AND DATA EXTRACTION: Forty-six publications were reviewed and criteria supporting the primary objective were used to identify useful resources. DATA SYNTHESIS: The literature included practice guidelines, review articles, original research articles, and prescribing information for the manifestations, diagnosis, and treatment of primary Sjögren's syndrome. CONCLUSION: Primary Sjögren's syndrome is a chronic autoimmune disease with various clinical manifestations, notably dry eye, dry mouth, fatigue, and inflammatory musculoskeletal pain. Most patients are under the care of a dentist, ophthalmologist, and rheumatologist. There is currently no cure; therapy is tailored for each patient to reduce symptoms, avoid complications, and improve quality of life. Respondents to a recent survey conducted by the Sjögren's Syndrome Foundation reported using more than eight medications and treatments for their symptoms; more than 60% of respondents were older than 60 years of age. Pharmacists familiar with recommended treatment options can provide advice and counseling to Sjögren's syndrome patients on multi-drug regimens prescribed by different health care practitioners.
The Chesapeake Regional Information System for our Patients (CRISP) is a health information exchange in Maryland that is designed to improve communication among members of the health care team including physicians, nurses, and other health professionals. Senior care pharmacists gained access to CRISP through successful collaborative efforts at both the state and national levels. This involved efforts to address medication-related problems that continue to be a concern during transitions of care, especially for older, vulnerable adults. Having access to recent clinical data assists the senior care pharmacist in providing medication therapy management services during transitions of care-the movement of a patient from one setting of care to another.This article highlights the importance of collaboration and advocacy between state and national leadership of the American Society of Consultant Pharmacists (ASCP) with key stakeholders to negotiate and gain access to such information for senior care pharmacists working in the post-acute and long-term care settings in Maryland.
OBJECTIVE:To determine whether advised changes as a result of structured medication reviews in psychogeriatric patients were implemented and if the implemented changes were maintained.DESIGN:Prospective cohort study.SETTING:Three nursing facilities in The Netherlands.PATIENTS, PARTICIPANTS:Newly admitted psychogeriatric residents.INTERVENTION:After admission, a structured medication review was performed by a pharmacist and physician resulting in a treatment plan that was approved by the patient's legal representative and implemented.MAIN OUTCOME MEASURE(S):The percentage of advised changes approved (= approval rate) and the percentage of implemented medication changes still present 90 days after approval (= 90-day implementation rate).RESULTS:A total of 45 patients were included who used a total number of 333 drugs (mean ± standard deviation 7.4 ± 3.3 drugs). Changes were advised to 159 medications used by 42 patients. Of these changes, 150 were approved (approval rate 94.3%). Finally, 105 were implemented, and 89 were still implemented after 90 days (90-day implementation rate 84.8%). Overall, 59.7% of the advised changes concerned deprescribing (stopping or dose reduction). The proportion of advised changes implemented was similar for symptommodifying and risk-modifying drugs, namely, almost 85%. Overall, 55.3% of the recommended changes to deprescribe concerned 10 drug groups.CONCLUSION:Medication could be successfully deprescribed from psychogeriatric patients after structured medication reviews performed by pharmacists and nursing facility physicians. More than 50% of the advised changes to deprescribe involved 10 drug groups, which raises the question whether the structured medication review can be performed more efficiently by focusing on the most common problems.
INTRODUCTIONTopical morphine is a potential treatment option for painful pressure ulcers in hospice and palliative care patients who favor avoidance of systemic opioid therapy.CASEA 65-year-old male African-American veteran with a painful stage 3 sacral pressure injury was hesitant to take systemic opioids to control his pain, as he wished to stay alert for family and friends. Topical morphine was initiated, and within 24 hours the patient reported a significant reduction in pain on the numeric rating scale.DISCUSSIONPalliative pharmacotherapy is focused on reducing the symptoms of disease while avoiding side effects that impair quality of life. Evidence suggests topical morphine can be an effective treatment option for painful pressure ulcers and can reduce the need for systemic opioids in select patients.CONCLUSIONIn the palliative care setting, topical morphine may be considered for compassionate use when treatment with systemic analgesics is undesired, inadequate, or poorly tolerated.
With a population that is increasingly "gray," our nation faces a shortage of primary care providers who specialize in geriatrics. The number of geriatricians per 10,000 adults older than 65 years of age has decreased steadily since 2000. Health care providers from all disciplines (medicine, nursing, and pharmacy) tend not to choose geriatrics as a specialty area. Some are intimidated by the complexity of caring for elderly patients with geriatric syndromes and multiple morbidities. Others, who have little exposure to geriatrics in their undergraduate and graduate programs, are simply unaware of the personal and professional rewards associated with practice in geriatrics. Some choose to pursue more lucrative career paths. Regardless, geriatrics is a rewarding area of specialty, and pharmacists can pursue additional training to become specialists. Few pharmacy curricula offer intense exposure to geriatrics and elder health care. Numerous ways exist for pharmacists to help close the geriatric care gap.
Proton pump inhibitors (PPIs) are commonly prescribed for treatment of acid-related gastrointestinal disorders. PPI use is approved for a duration of 2 to 12 weeks, depending on complication and severity. Many users lack an appropriate indication for continued therapy past the recommended duration. Long-term PPI use is associated with several adverse drug events, including acute interstitial nephritis, fractures, and Clostridium difficile-associated diarrhea (CDAD). Cautious prescribing and regular monitoring is essential, especially for older adults, as they may be at higher risk for these adverse effects. Deprescribing, defined as lowering dosage, switching to as-needed use, or complete discontinuation, should be considered for many PPI users. Patient education is critical. Alternative therapy considerations include histamine-2-receptor antagonists, as they are found to be associated with reduced CDAD and fracture events. Additional strategies include tapering off PPIs and modifying lifestyle to reduce the potential rebound hypersecretion that may occur as a result of discontinuation. The most significant lifestyle modification is weight loss. Additional lifestyle interventions include upright head of bed elevation, avoiding meals close to bedtime, and avoiding high-fat meals within two to three hours of reclining.
Urinary tract infections (UTIs) are one the of the most common types of infections in adults older than 65 years of age. Preventing UTIs with prophylactic antibiotics increases the risk of side effects and microbial resistance, and is costly. Cranberry fruit and juices contain the compound proanthrocyanidins (PACs), specifically proanthrocyanidin-A, which exerts antiadhesion characteristics against bacteria. Cranberry products therefore have been an attractive, nonantibiotic preventative option for UTIs; however, the current literature supporting cranberry use in older adults is controversial. This could be multifactorial owing to the heterogeneity of the older population as well as inconsistencies in the recommended dose of PAC in the current literature. Evidence supports that cranberry may be beneficial in preventing UTIs in specific populations such as catheter-associated UTI and postradiotherapy prostate cancer. The cost of daily capsules versus the cost of preventing a UTI in older adults is an important consideration for initiating therapy.
Since Food and Drug Administration approval of dabigatran in 2010, direct oral anticoagulants (DOACs) have been alternatives to warfarin for patients who are at risk for cardioembolic complications of nonvalvular atrial fibrillation. Unfortunately, there are limited safety data available on the use of these newer agents in older adults, particularly risks of gastrointestinal, intracranial, and major bleeding (as defined by the International Society on Thrombosis and Haemostasis) in those 75 years of age and older. The purpose of this manuscript is to provide a review of available literature regarding the risk of bleeding in older adults for each DOAC based on available retrospective cohort, secondary, and subgroup analyses, and to highlight the need for additional safety information in this population.
OBJECTIVE: To review and summarize studies on the effects of denosumab on bone mineral density following the discontinuation of therapy.DATA SOURCES: A search of PubMed (1966-July 2017) and International Pharmaceutical Abstracts (1970-July 2017) was conducted using the Medical Subject Headings (MeSH) terms denosumab, osteoporosis, and withholding treatment in combination with free term searches including the words drug holiday, discontinue, discontin*, and drug discontinuation.STUDY SELECTION AND DATA EXTRACTION: An initial review yielded 10 articles. Four articles that addressed the effects of denosumab discontinuation on markers of overall bone health, fracture risk, or bone histology were included in the final review.DATA SYNTHESIS: Denosumab is a monoclonal antibody indicated for the treatment of osteoporosis in men and postmenopausal women. Denosumab has proven beneficial effects on bone remodeling and bone mineral density, and these effects have been noted to be reversed upon treatment discontinuation because of the agent's lack of incorporation into bone matrix. After 12 to 24 months off denosumab therapy, BMD, BTMs levels, as well as histologic and histomorphometric analyses, were reflective of baseline values. The number of studies evaluating the residual skeletal effects of denosumab is limited, and the sample sizes in the articles reviewed were relatively small.CONCLUSION: An evaluation of studies showed that the discontinuation of denosumab results in loss of bone mineral density and a decline to near baseline values within 12 months of discontinuing therapy. Larger extension studies in a more diverse population need to be conducted to extrapolate the data to other patient groups.
OBJECTIVE Vaccines are a low-cost, high-impact interventions that effectively and efficiently reduce the burden of infectious diseases. Many rural populations have vaccination rates well below nationally recommended levels. Community pharmacies may offer a solution to this problem. Under a collaborative drug therapy agreement (CDTA), pharmacists can prescribe and administer immunizations. The purpose of this study was to examine pneumococcal vaccine access in rural pharmacies in Eastern Washington state. DESIGN A qualitative descriptive design was utilized in this study. The sample included all pharmacies located in two rural Washington state counties. Interviews were conducted with pharmacy staff. Every pharmacy in the two counties was surveyed over the telephone. Data analysis included directed content analysis and descriptive statistics. FINDINGS Each of the 10 pharmacies identified participated. Pharmacy volume varied (weekly prescription counts of 300 to 2,500). Sixty percent of pharmacies currently provide vaccines. Quoted prices of the PCV13 varied between $65 and $228. Quoted prices of the PPSV23 varied between $64 and $120. Pharmacies that vaccinated made it convenient with "walk-in" scheduling practices. Some pharmacies required a prescription from a separate provider while others could prescribe on-site through CDTA. Pharmacies that chose not to vaccinate did so for a variety of reasons. CONCLUSIONS Access to pneumococcal vaccines will be enhanced by pharmacist administration, resulting in improved availability, accessibility, accommodation, affordability, and acceptability for patients in rural Washington.
As patients age, they are predisposed to certain disease states such as chronic obstructive pulmonary disease (COPD). Physiologic changes that occur during aging as well as guidelines for treatment must be considered in providing pharmaceutical care for older adults. Preferred treatment options have special considerations in the aging population because of the inability to use certain inhaler devices and medications appropriately. This paper reviews physiologic changes in geriatric adults, COPD treatment, medications that should be avoided in this population, and special considerations for geriatric patients with COPD.
Obtaining and maintaining adequate blood glucose control in the older adult with diabetes offers unique challenges. Intensive blood glucose control can increase the risk of hypoglycemia, which can be particularly risky in the older adult. Adding and adjusting diabetes medications in elderly patients with multiple comorbidities and numerous other medications can also be challenging. The use of professional continuous glucose monitors-which are worn by the patient for up to two weeks and record blood sugars every 5 to 15 minutes-provides pharmacists and other health care professionals with valuable data for managing the care of the older adult with diabetes.
