OBJECTIVES: To evaluate whether use of certain medications with potential urological effects is associated with development of incident urinary incontinence in community‐resident older women.DESIGN: Longitudinal cohort study.SETTING: Pittsburgh, PA, and Memphis, TN.PARTICIPANTS: Nine hundred fifty‐nine healthy black and white women aged 65 and older enrolled in the Health, Aging and Body Composition Study without baseline (Year 1) self‐reported urinary incontinence.MEASUREMENTS: Use of alpha blockers, anticholinergics, central nervous system medications (opioids, benzodiazepines, antidepressants, antipsychotics), diuretics (thiazide, loop, potassium sparing), and estrogen (all dosage forms) was determined during Year 3 interviews. Self‐reported incident (≥weekly) incontinence in during the previous 12 months was assessed at Year 4 interviews.RESULTS: Overall, 20.5% of these women reported incident incontinence at Year 4 (3 years from baseline). The most common medication used with potential urological activity was a thiazide diuretic (24.3%), followed by estrogen (22.2%); alpha blockers were the least commonly used (2.3%). Multivariable logistic regression analyses revealed that current users of alpha blockers (adjusted odds ratio (AOR)=4.98, 95% confidence interval (CI)=1.96–12.64) and estrogen (AOR=1.60, 95% CI=1.08–2.36) had a greater risk of urinary incontinence than nonusers. There was no greater risk (P>.05) of urinary incontinence with the current use of anticholinergics, central nervous system medications, or diuretics. No statistically significant race‐by–medication use interactions were found (all P>.05).CONCLUSION: These results corroborate earlier reports that, in elderly women, use of alpha blockers or estrogens is associated with risk of self‐reported incident urinary incontinence.

Objective: The purpose of this study is to evaluate whether the use of medications with urological activity (UA) is associated with self-reported difficulty in control of urination. Methods: This is a cross-sectional study using data from the Duke Established Populations for Epidemiologic Studies of the Elderly. Results: Difficulty holding urine was reported by 49.5% of men and 54.0% of the women. Overall, 50.9% of men and 72.7% of the women took one or more medications with UA. Multivariable logistic regression for men revealed that neither use of any medication with UA (Adjusted [Adj.] Odds Ratio [OR] 1.12, 95% confidence interval [CI] 0.84-1.50) nor the number of medications with UA used was associated with urinary difficulties (Adj. OR 1.08, 95% CI 0.97-1.21). For women, there was a significant association (p < .05) between use of any medication with UA and reported urinary difficulty (Adj. OR = 1.31, 95% CI = 1.05-1.62). Discussion: Medications with UA may be related to difficulty in controlling urine among community-dwelling elderly women.

Objectives: To determine the prevalence and predictors of unnecessary drug use at hospital discharge in frail elderly patients.Design: Cross‐sectional.Setting: Eleven Veterans Affairs Medical Centers.Participants: Three hundred eighty‐four frail older patients from the Geriatric Evaluation and Management Drug Study.Measurements: Assessment of unnecessary drug use was determined by the consensus of a clinical pharmacist and physician pair applying the Medication Appropriateness Index to each regularly scheduled medication at hospital discharge. Those drugs that received an inappropriate rating for indication, efficacy, or therapeutic duplication were defined as unnecessary.Results: Forty‐four percent of patients had at least one unnecessary drug, with the most common reason being lack of indication. The most commonly prescribed unnecessary drug classes were gastrointestinal, central nervous system, and therapeutic nutrients/minerals. Factors associated (P<.05) with unnecessary drug use included hypertension (adjusted odds ratio (AOR)=0.61, 95% confidence interval (CI)=0.38–0.96), multiple prescribers (AOR=3.35, 95% CI=1.16–9.68), and nine or more medications (AOR=2.24, 95% CI=1.25–3.99).Conclusion: A high prevalence of unnecessary drug use at discharge was found in frail hospitalized elderly patients. Additional studies are needed to identify predictors and prevalence of unnecessary drug use in nonveteran populations so that interventions can be designed to reduce the problem.

Inappropriate drug therapy is defined as a therapy whose adverse risks exceed its health benefits.1 Inappropriate prescribing is common among the elderly2–,6 and has been associated with increased health care costs and poor patient outcomes.7–,11 Some 21% of community-dwelling elderly people and 40% of nursing-home residents have received at least one potentially inappropriate drug.12,13 As the U.S. population ages, the problem of inappropriate drug therapy is likely to grow. Underutilization of drug therapy occurs when an indicated drug is omitted from patients’ medication regimens despite no documented contraindication to therapy. Underutilization of β-blockers,14–,16 angiotensin-converting-enzyme (ACE) inhibitors,15,16 warfarin, and aspirin is common among the elderly. The rate of utilization of ACE inhibitors for congestive heart failure, β-blockers and aspirin for coronary artery disease, and warfarin for atrial fibrillation remained consistently below 60% between 1990 and 2002.16 In 2001, the rate of use of ACE inhibitors, β-blockers, aspirin, and warfarin for indicated diseases was 39%, 40%, 38%, and 58%, respectively. Underutilization of cardiac drugs with proven benefits can worsen therapeutic outcomes and increase morbidity and mortality among the elderly.

BACKGROUND: Drugs can improve quality of life for many older people, but they may cause adverse health outcomes (eg, drug—disease interactions) if used inappropriately. OBJECTIVE: To determine the prevalence of potential drug—disease interactions as defined by explicit criteria and examine associations between sociodemographic and health status variables and potential drug—disease interactions. METHODS: The study design was cross-sectional. We evaluated 397 frail elderly inpatients from the Geriatric Evaluation and Management trial conducted at 11 Veterans Affairs Medical Centers. Drug—disease interactions were defined using explicit criteria from consensus expert panels of geriatricians from the US and Canada. RESULTS: Overall, 159 (40.1%) patients had one or more potential drug—disease interaction. The most common potential interactions were calcium-channel blockers and heart failure (12.3%) and β-blockers and diabetes (6.8%). Multivariable logistic regression analyses revealed that age ⩾75 years (adjusted OR 2.43; 95% CI 1.52 to 3.88), being married (adjusted OR 1.77; 95% CI 1.11 to 2.82), comorbidity index defined by Charlson method (adjusted OR 1.19; 95% CI 1.05 to 1.34), and use of multiple prescription drugs (5–8: adjusted OR 4.17; 95% CI 1.96 to 8.88, ⩾9: adjusted OR 9.22; 95% CI 4.26 to 19.95), were significantly (p < 0.05) associated with having one or more potential drug—disease interaction. CONCLUSIONS: Potential drug—disease interactions are common in hospitalized elderly patients and are related to specific sociodemographic and health status factors. Further research is needed to examine the relationship between health outcomes and drug—disease interactions.

PURPOSE: To determine if inpatient or outpatient geriatric evaluation and management, as compared with usual care, reduces adverse drug reactions and suboptimal prescribing in frail elderly patients.METHODS: The study employed a randomized 2 x 2 factorial controlled design. Subjects were patients in 11 Veterans Affairs (VA) hospitals who were greater than or equal to65 years old and met criteria for frailty (n = 834). Inpatient geriatric unit and outpatient geriatric clinic teams evaluated and managed patients according to published guidelines and VA standards. Patients were followed for 12 months. Blinded physician-pharmacist pairs rated adverse drug reactions for causality (using Naranjo's algorithm) and seriousness. Suboptimal prescribing measures included unnecessary and inappropriate drug use (Medication Appropriateness Index), inappropriate drug use (Beers criteria), and underuse.RESULTS: For serious adverse drug reactions, there were no inpatient geriatric unit effects during the inpatient or outpatient follow-up periods. Outpatient geriatric clinic care resulted in a 35% reduction in the risk of a serious adverse drug reaction compared with usual care (adjusted relative risk = 0.65; 95% confidence interval: 0.45 to 0.93). Inpatient geriatric unit care reduced unnecessary and inappropriate drug use and underuse significantly during the inpatient period (P < 0.05). Outpatient geriatric clinic care reduced the number of conditions with omitted drugs significantly during the outpatient period (P < 0.05).CONCLUSION: Compared with usual care, outpatient geriatric evaluation and management reduces serious adverse drug reactions, and inpatient and outpatient geriatric evaluation and management reduces suboptimal prescribing, in frail elderly patients. (C) 2004 by Excerpta Medica Inc.

BACKGROUND:Adverse drug reactions (ADRs) are common in older (age >or=65 years) outpatients (prevalence, 5%-35%), but there is no consensus on factors that put these patients at high risk for ADRs. Identifying a uniform set of risk factors would be helpful to develop risk models for ADRs for older outpatients and to implement targeted interventions for those patients at high risk for ADRs. OBJECTIVE:The aim of this study was to identify potential risk factors for ADRs in older outpatients through a survey of geriatric experts and to determine their prevalence. METHODS:A comprehensive literature search was conducted to find published articles on ADRs in older patients. Forty-four potential risk factors were identified through the literature search and 6 additional factors were suggested by the expert panel. Through a modified 2-round survey, based on the Delphi consensus method, of an expert panel of 5 physicians and 5 pharmacists, the probability that each of these 50 potential factors could contribute independently to placing an older outpatient at high risk for an ADR was rated on a 5-point Likert scale. After the survey responses were received, means and 95% Cls were calculated. Consensus was defined as a lower 95% confidence limit >or=4.0. Potential risk factors that reached consensus were then applied to a sample of older outpatients to determine their prevalence. RESULTS:After 2 rounds, the expert panel reached consensus on 21 factors, including 12 medication-related factors and 9 patient characteristics. The most prevalent medication-related risk factors were opioid analgesics; warfarin; non-acetylsalicylic acid, non-cyclooxygenase-2 nonsteroidal anti-inflammatory drugs; anticholinergics; and benzodiazepines. The most prevalent patient characteristics included polypharmacy, multiple chronic medical problems, prior ADR, and dementia. CONCLUSIONS:An expert panel was able to reach a consensus on potential risk factors that increase the risk for ADRs in older outpatients. Many risk factors were common in a sample of older outpatients. Future research is needed to determine the predictive validity of these risk factors for ADRs in older outpatients.

OBJECTIVES To determine the prevalence and predictors of inappropriate drug prescribing defined by expert national consensus panel drug utilization review criteria for community-dwelling older people. DESIGN Survey. SETTING Five adjacent urban and rural counties in the Piedmont area of North Carolina. PARTICIPANTS A stratified random sample of participants from the fourth (n = 3,234) and seventh (n = 2,508) waves of the Duke Established Populations for Epidemiological Studies of the Elderly. MEASUREMENTS The prescribing appropriateness for digoxin, calcium channel blockers, angiotensin-converting enzyme inhibitors, histamine(2) receptor antagonists, nonsteroidal antiinflammatory drugs (NSAIDs), benzodiazepines, antipsychotics, and antidepressants as determined by explicit criteria (through Health Care Financing Administration expert consensus panel drug utilization review criteria for dosage, duplication, drug-drug interactions and duration, and U.S. and Canadian expert consensus panel criteria for drug-disease interactions). Multivariable analyses, using weighted data adjusted for sampling design, were conducted to assess the association between inappropriate prescribing and demographic, health-status, and access-to-healthcare factors cross-sectionally and longitudinally. RESULTS We found that 21.0 of the fourth wave and 19.2 of the seventh wave participants who used one or more agents from the eight drug classes had one or more elements identified as inappropriate. The therapeutic classes with the most problems were benzodiazepines and NSAIDs. The most common problems were with drug-disease interactions and duration of use. Longitudinal multivariable analyses found that participants who were white (adjusted odds ratio (AOR) = 1.67, 95 confidence interval (CI) = 1.28-2.17), were married (AOR = 1.40, 95% CI = 1.01-1.93), had arthritis (AOR = 1.74, 95% CI = 1.27-2.38), had one or more physical function disabilities (AOR = 1.42, 95% CI = 1.02-1.96), and had inappropriate drugs prescribed at wave 4 (AOR = 6.87, 95% CI = 5.11-9.22) were more likely to have inappropriate prescribing at wave 7. CONCLUSION These results indicate that inappropriate prescribing is common among community-dwelling older people and persists over time. Longitudinal studies in older people are needed to examine the impact of inappropriate drug prescribing on health-related outcomes.

Journal Article Comparison of methods for detecting potential adverse drug events in frail elderly inpatients and outpatients Get access Joseph T. Hanlon, Pharm.D., M.S., FASCP, FASHP, Joseph T. Hanlon, Pharm.D., M.S., FASCP, FASHP Director Institute for the Study of Geriatric Pharmacotherapy; Professor, College of Pharmacy, Department of Experimental and Clinical Pharmacology; and Adjunct Professor, School of Public Health, Division of Health Services Research and Policy, University of Minnesota (UM), Minneapolis; and Clinical Pharmacy Specialist—Geriatrics, Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center (VAMC), Minneapolis Address correspondence to Dr. Hanlon at the College of Pharmacy, 7-115 Weaver- Densford Hall, University of Minnesota, 308 Harvard Street, S.E., Minneapolis, MN 55455 (hanlo004@tc.umn.edu). Search for other works by this author on: Oxford Academic Google Scholar Robert L. Maher, Pharm.D., Robert L. Maher, Pharm.D. Assistant Professor Mylan College of Pharmacy, Duquesne University, Pittsburgh, PA Search for other works by this author on: Oxford Academic Google Scholar Catherine I. Lindblad, Pharm.D., Catherine I. Lindblad, Pharm.D. Geriatric Pharmacotherapy Research Fellow Institute for the Study of Geriatric Pharmacotherapy, and Instructor, College of Pharmacy, Department of Experimental and Clinical Pharmacology, UM Search for other works by this author on: Oxford Academic Google Scholar Christine M. Ruby, Pharm.D., Christine M. Ruby, Pharm.D. Assistant Research Professor Department of Medicine, Division of Geriatrics, and Senior Fellow, Center for the Study of Aging and Human Development, Duke University Medical Center (DUMC), Durham, NC; Clinical Pharmacy Specialist—Geriatrics, Geriatric Research, Education, and Clinical Center, VAMC, Durham; and Clinical Assistant Professor, School of Pharmacy, University of North Carolina, Chapel Hill Search for other works by this author on: Oxford Academic Google Scholar Jack Twersky, M.D., Jack Twersky, M.D. Assistant Clinical Professor Department of Medicine, Division of Geriatrics, and Senior Fellow, Center for the Study of Aging and Human Development, DUMC; and Staff Physician, Geriatric Research, Education, and Clinical Center, VAMC, Durham Search for other works by this author on: Oxford Academic Google Scholar Harvey J. Cohen, M.D., Harvey J. Cohen, M.D. Professor Department of Medicine; Chief, Division of Geriatrics; and Director, Center for the Study of Aging and Human Development, DUMC; and Director, Geriatric Research, Education, and Clinical Center, VAMC, Durham Search for other works by this author on: Oxford Academic Google Scholar Kenneth E. Schmader, M.D. Kenneth E. Schmader, M.D. Associate Professor Department of Medicine, Division of Geriatrics, and Senior Fellow, Center for the Study of Aging and Human Development, DUMC; and Staff Physician, Geriatric Research, Education, and Clinical Center, VAMC, Durham Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 58, Issue 17, 1 September 2001, Pages 1622–1626, https://doi.org/10.1093/ajhp/58.17.1622 Published: 01 September 2001

The objective of this article was to review the recent literature (1990-1995) on drugs and falls in the older population. A computerized literature search identified 19 research articles. The quality of each study was critically evaluated, and a consistent risk relationship between the use of psychotropic drugs and falls was identified. Moreover, polypharmacy and certain cardiovascular agents may be associated with falls. Finally, it is controversial as to whether certain agents (eg, analgesics, hypoglycemics) are associated with falls. Future studies are necessary to better understand the relationship between drugs and falls in the older adult.