Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States

Dietary Supplement Use Was Very High among Older Adults in the United States in 2011-2014

Background: Dietary supplements (DSs) have the potential to be both beneficial and harmful to health, especially in adults aged ≥60 y, and therefore it is important to monitor the patterns of their use.Objective: This study evaluated DS use by adults aged ≥60 y to characterize the use of DSs, determine the motivations for use, and examine the associations between the use of DSs and selected demographic, lifestyle, and health characteristics.Methods: Data from 3469 older adults aged ≥60 y from the 2011-2014 NHANES were analyzed. DSs used in the past 30 d were ascertained via an interviewer-administered questionnaire in participants' homes. The prevalence of overall DS use and specific types of DSs were estimated. The number of DSs reported and the frequency, duration, and motivation(s) for use were assessed. Logistic regression models were constructed to examine the association between DS use and selected characteristics.Results: Seventy percent of older adults in the United States reported using ≥1 DS in the past 30 d; 54% of users took 1 or 2 products, and 29% reported taking ≥4 products. The most frequently reported products were multivitamin or mineral (MVM) (39%), vitamin D only (26%), and omega-3 fatty acids (22%). Women used DSs almost twice as often as men [adjusted OR (aOR), 1.8; 95% CI: 1.5, 2.3). Those not reporting prescription medications were less likely to take a DS than those reporting ≥3 prescription medications (aOR, 0.4; 95% CI: 0.3, 0.6). The most frequently reported motivation for DS use was to improve overall health (41%).Conclusions: Use of DSs among older adults continues to be high in the United States, with 29% of users regularly taking ≥4 DSs, and there is a high concurrent usage of them with prescription medications.

Human Factors in Pharmacy

Medication errors in the ambulatory setting are common and contribute to significant morbidity and mortality. Given the Institute of Medicine’s recommendation of adopting a systems-based approach to improving medication safety, research has been conducted utilizing human factors and ergonomics conceptual frameworks, approaches, and methods to study pharmacies and pharmacists. This panel will focus on how human factors principles and models have been adapted for contexts where medications are managed. Individual projects address pediatric patients’ medication-related needs, over-the-counter medication safety for older adults, anticoagulation management, automated prescription tracking, and medication safety-related decision making by healthcare professionals. These studies span settings from community pharmacies to inpatient pharmacies to specialty clinics and patients’ homes. By presenting a sample of the growing body of human factors work in pharmacy, this panel will offer unique implications for human factors theory, methods, and application in this important domain.

Medication and supplement use in older people with and without intellectual disability: An observational, cross-sectional study

Introduction

Understanding the medication and supplement use of aging people is critical to ensuring that health service providers in primary care can optimise use of these agents. An increasing number of people with different levels of intellectual disability (ID) are living in the community and becoming for the first time substantial users of primary health care services. This, however, brings new challenges that need to be addressed at the primary health care level. We quantified the use of medicines and food supplements and described the associated patterns of morbidity in the two comparable cohorts of aging population with and without intellectual disability.

Method

This research aligned participants of 50 years and over who lived in the community from two nationally representative cohorts of older people; those with ID from the Intellectual Disability Supplement (n = 238) and those without ID (n = 8,081) from the Irish Longitudinal Study on Ageing.

Results

Data showed that both medication and supplement use in the two groups was prevalent but that those with ID received more of both medications and supplements (e.g. polypharmacy was 39.0% in ID vs. 18.1% in non-ID cohort). Moreover, based on an analysis of the therapeutic groups and medications used that treatment was more intense in the ID cohort (95.8 vs. 7.0 International Non-proprietary Names per 100 participants). Supplement use was almost twice as prevalent in the ID group but substantially less diverse with only 10 types of supplements reported. Morbidity was higher in the ID group and showed a higher prevalence of neurological and mental health disorders.

Conclusion

The results highlight that the burden of therapy management and the potential risks in those ageing with ID differs substantially from those ageing without ID. Understanding the medication and supplement use of people aging with intellectual disability (ID) is critical to ensuring that health service providers in primary/ambulatory care can optimise use of these agents.

Prevalence and predictors of potentially inappropriate prescribing of central nervous system and psychotropic drugs among elderly patients: A national population study in Korea

OBJECTIVES

To investigate the prevalence of potentially inappropriate prescribing (PIP) of central nervous system and psychotropic (CNS-PS) drugs to the Korean elderly population, and to identify PIP-associated factors.

METHODS

Ambulatory care visits were identified from the 2013 National Aged Patient Sample (HIRA-APS-2013) data, composed of 20% random samples of all enrollees in the universal health security program aged ≥65 years. The CNS-PS section of Screening Tool of Older Person's potentially inappropriate Prescriptions (STOPP) criteria version 2 was used to identify PIP at these visits.

RESULTS

A total of 24,427,069 prescription claims records and 1,122,080 patients were included in the study; 10.73% of the claims and 53.64% of the patients satisfied at least one STOPP criterion in the prescription of CNS-PS drugs. The highest prevalence of PIP was observed for the criteria of "first-generation antihistamines" (FGAH), followed by tricyclic antidepressants (TCA) in patients with prostatism and TCA in patients with dementia. The generalized estimating equation logistic regression analysis showed that the PIP of FGAH was significantly associated with polypharmacy (5-9 drugs: odds ratio (OR) 4.965, 95% confidence interval (CI) 4.936-4.994; ≥10 drugs: OR 5.704, 95% CI 5.604-5.807), less severe health conditions (Charlson Comorbidity Index (CCI)=2: OR 0.852, 95% CI 0.842-0.862; CCI=1: OR 0.975, 95% CI 0.964-0.986), prescriptions from clinics (OR>1.0), and outpatient care by general practitioners (OR>1.0).

CONCLUSIONS

Appropriate interventions to reduce PIP should be made, especially for the criteria that indicate a high PIP prevalence. Targeted strategies are necessary to modify the risk factors of PIP identified from this study.

Factors associated with self-medication in Spain: a cross-sectional study in different age groups

Objective

The identification of factors which may influence a patient’s decision to self-medicate.

Methods

Descriptive, cross-sectional study of the adult population (at least 16 years old), using data from the 2009 European Health Interview Survey in Spain, which included 22 188 subjects. Logistic regression models enabled us to estimate the effect of each analysed variable on self-medication.

Key findings

In total, 14 863 (67%) individuals reported using medication (prescribed and non-prescribed) and 3274 (22.0%) of them self-medicated. Using logistic regression and stratifying by age, four different models have been constructed. Our results include different variables in each of the models to explain self-medication, but the one that appears on all four models is education level. Age is the other important factor which influences self-medication. Self-medication is strongly associated with factors related to socio-demographic, such as sex, educational level or age, as well as several health factors such as long-standing illness or physical activity.

Conclusions

When our data are compared to those from previous Spanish surveys carried out in 2003 and 2006, we can conclude that self-medication is increasing in Spain.

Ibuprofen before Exercise Does Not Prevent Cortical Bone Adaptations to Training

Using a nonsteroidal anti-inflammatory drug (NSAID) before a single bout of mechanical loading can reduce bone formation response. It is unknown whether this translates to an attenuation of bone strength and structural adaptations to exercise training.

PURPOSE

This study aimed to determine whether nonsteroidal anti-inflammatory drug use before exercise prevents increases in bone structure and strength in response to weight-bearing exercise.

METHODS

Adult female Wistar rats (n = 43) were randomized to ibuprofen (IBU) or vehicle (VEH) and exercise (EX) or sedentary (SED) groups in a 2 × 2 (drug and activity) ANCOVA design with body weight as the covariate, and data are reported as mean ± SE. IBU drops (30 mg·kg BW) or VEH (volume equivalent) were administered orally 1 h before the bout of exercise. Treadmill running occurred 5 d·wk for 60 min·d at 20 m·min with a 5° incline for 12 wk. Micro-CT, mechanical testing, and finite element modeling were used to quantify bone characteristics.

RESULTS

Drug-activity interactions were not significant. Exercise increased tibia cortical cross-sectional area (EX = 5.67 ± 0.10, SED = 5.37 ± 0.10 mm, P < 0.01) and structural estimates of bone strength (Imax: EX = 5.16 ± 0.18, SED = 4.70 ± 0.18 mm, P < 0.01; SecModPolar: EX = 4.01 ± 0.11, SED = 3.74 ± 0.10 mm, P < 0.01). EX had increased failure load (EX = 243 ± 9, SED = 202 ± 7 N, P < 0.05) and decreased distortion in response to a 200-N load (von Mises stress at tibia-fibula junction: EX = 48.2 ± 1.3, SED = 51.7 ± 1.2 MPa, P = 0.01). There was no effect of ibuprofen on any measurement tested. Femur results revealed similar patterns.

CONCLUSION

Ibuprofen before exercise did not prevent the skeletal benefits of exercise in female rats. However, exercise that engenders higher bone strains may be required to detect an effect of ibuprofen.

Sixty Challenges – A 2030 Perspective on Natural Products and Medicines Security

Natural products matter, for they are essential contributors to societal well-being and global health. Flavors, fragrances, essential oils, traditional medicines and phytopharmaceuticals, and prescription and over-the-counter products all utilize constituent materials from natural sources. However, these vast natural resources of Earth are disappearing, and climate change and market expansion by a dramatically increasing and ageing population will continue to strain plant sourcing in the decades ahead. It was with these and other considerations that the term “ecopharmacognosy” was developed as both a philosophy and a practice, and from which the necessity for a “medicines security” strategy evolved.

Extending previous presentations, a series of sixty challenges for 2030 to the status quo promotes the discussion of a different vision for the natural product sciences as applied to traditional medicines. Among the topics presented are areas for global collaborative initiatives in science and in data management, the impact of climate change on medicinal plant accessibility, the sustainability and quality of the natural products that patients receive, and the integration of new technologies, particularly the genomics of secondary metabolite biosynthesis, hand-held detection systems and artificial intelligence, and the implications of increased life expectancy on future health care needs. The presentation closes with two examples of newer approaches in drug discovery.

Effects of aging and rifampicin pretreatment on the pharmacokinetics of human cytochrome P450 probes caffeine, warfarin, omeprazole, metoprolol and midazolam in common marmosets genotyped for cytochrome P450 2C19

1. The pharmacokinetics were investigated for human cytochrome P450 probes after single intravenous and oral administrations of 0.20 and 1.0 mg/kg, respectively, of caffeine, warfarin, omeprazole, metoprolol and midazolam to aged (10-14 years old, n = 4) or rifampicin-treated/young (3 years old, n = 3) male common marmosets all genotyped as heterozygous for a cytochrome P450 2C19 variant. 2. Slopes of the plasma concentration-time curves after intravenous administration of warfarin and midazolam were slightly, but significantly (two-way analysis of variance), decreased in aged marmosets compared with young marmosets. The mean hepatic clearances determined by in silico fitting for individual pharmacokinetic models of warfarin and midazolam in the aged group were, respectively, 23% and 56% smaller than those for the young group. 3. Significantly enhanced plasma clearances of caffeine, warfarin, omeprazole and midazolam were evident in young marmosets pretreated with rifampicin (25 mg/kg daily for 4 days). Two- to three-fold increases in hepatic intrinsic clearance values were observed in the individual pharmacokinetic models. 4. The in vivo dispositions of multiple simultaneously administered drugs in old, young and P450-enzyme-induced marmosets were elucidated. The results suggest that common marmosets could be experimental models for aged, induced or polymorphic P450 enzymes in P450-dependent drug metabolism studies.

The attitudes and beliefs of doctors towards deprescribing medications

Background:

The effects of polypharmacy and its related adverse outcomes are well documented among elderly patients. Deprescribing is now recognised as an important part of medication review in addressing polypharmacy. However, little is currently known about local practices in discontinuing medications as a means to improve quality of life. There are two aims in this study: first, to explore the attitudes and beliefs of deprescribing medications among doctors in the Department of Internal Medicine (DIM) in Singapore General Hospital (SGH), and second, to see if differences exist among junior and senior doctors in their attitudes towards deprescribing.

Methods:

A descriptive survey was designed to look at the attitudes and beliefs of doctors towards deprescribing. All doctors in the department were invited to complete the survey.

Results:

The majority of doctors (66%) believed that deprescribing is beneficial for patients. Commonly cited barriers towards deprescribing were unwillingness to stop medications prescribed by another doctor, lack of time and insufficient knowledge. Lack of a specific approach to deprescribing was noted among 73% of the participants. A third of the juniors (32%) stated that they were reluctant to deprescribe medications, which was in contrast to the responses by the seniors, most of whom (94%) indicated no reluctance in deprescribing medications.

Conclusion:

Most doctors believe that deprescribing is beneficial to patients. Specific measures to target the barriers faced by doctors in deprescribing medications are necessary to improve deprescribing rates and minimising polypharmacy.

Herbal Medications in Cardiovascular Medicine

Herbal medications are commonly used for clinical purposes, including the treatment of cardiovascular conditions. Compared with conventional medications, herbal medications do not require clinical studies before their marketing or formal approval from regulatory agencies, and for this reason their efficacy and safety are rarely proven. In this review, we summarize available evidence on herbal medications mostly used in cardiovascular medicine. We show that the use of these medications for the treatment of cardiovascular diseases is often not supported by scientific evidence. Despite most of these herbs showing an effect on biological mechanisms related to the cardiovascular system, data on their clinical effects are lacking. Potential relevant side effects, including increased risk of drug interactions, are described, and the possibility of contamination or substitution with other medications represents a concern. Physicians should always assess the use of herbal medications with patients and discuss the possible benefits and side effects with them.

Impact of Aging and Cytomegalovirus on Immunological Response to Influenza Vaccination and Infection

The number of people over the age of 60 is expected to double by 2050 according to the WHO. This emphasizes the need to ensure optimized resilience to health stressors in late life. In older adults, influenza is one of the leading causes of catastrophic disability (defined as the loss of independence in daily living and self-care activities). Influenza vaccination is generally perceived to be less protective in older adults, with some studies suggesting that the humoral immune response to the vaccine is further impaired in cytomegalovirus (CMV)-seropositive older people. CMV is a β-herpes virus infection that is generally asymptomatic in healthy individuals. The majority of older adults possess serum antibodies against the virus indicating latent infection. Age-related changes in T-cell-mediated immunity are augmented by CMV infection and may be associated with more serious complications of influenza infection. This review focuses on the impact of aging and CMV on immune cell function, the response to influenza infection and vaccination, and how the current understanding of aging and CMV can be used to design a more effective influenza vaccine for older adults. It is anticipated that efforts in this field will address the public health need for improved protection against influenza in older adults, particularly with regard to the serious complications leading to loss of independence.

Deregulation of sale of over-the-counter drugs outside of pharmacies in the Republic of Korea: interrupted-time-series analysis of outpatient visits before and after the policy

BACKGROUND

We evaluated the effectiveness of a policy allowing for the sale of over-the-counter drugs outside of pharmacies by examining its effect on number of monthly outpatient visits for acute upper respiratory infections, dyspepsia, and migraine.

METHOD

We used medical claims data extracted from the Korean National Health Insurance Cohort Database from 2009 to 2013. The Korean National Health Insurance Cohort Database comprises a nationally representative sample of claims - about 2% of the entire population - obtained from the medical record data held by the Korean National Health Insurance Corporation (which has data on the entire nation). The analysis included26,284,706 person-months of 1,042,728 individuals. An interrupted-time series analysis was performed. Outcome measures were monthly outpatient visits for acute upper respiratory infections, dyspepsia, and migraine. To investigate the effect of the policy, we compared the number of monthly visits before and after the policy's implementation in 2012.

RESULT

For acute upper respiratory infections, monthly outpatient visits showed a decreasing trend before the policy (ß = -0.0003);after it, a prompt change and increasing trend in monthly outpatient visits were observed, but these were non-significant. For dyspepsia, the trend was increasing before implementation (ß = -0.0101), but this reversed after implementation(ß = -0.007). For migraine, an increasing trend was observed before the policy (ß = 0.0057). After it, we observed a significant prompt change (ß = -0.0314) but no significant trend.

CONCLUSION

Deregulation of selling over-the-counter medication outside of pharmacies reduced monthly outpatient visits for dyspepsia and migraine symptoms, but not acute upper respiratory infections.

Hallucinations in Healthy Older Adults: An Overview of the Literature and Perspectives for Future Research

KEY POINTS

➢ Studies suggest a substantial minority of healthy older adults have hallucinatory experiences, in line with existing evidence on hallucinations in other age groups, though it is still unclear if hallucination prevalence increases or declines with age in older cohorts.

➢ Stigma attached to both hallucinations and ageing leads to considerable under-reporting of these experiences in healthy older adults and may negatively bias how professionals, family members, and the public respond.

➢ Why and when hallucinations in healthy older adults remit, persist, or progress to other clinical disorders remains poorly understood.

➢ Current evidence points to a range of factors associated with hallucinations in older adults including decline in sensory or cognitive functioning, poor sleep, and psychosocial stressors (e.g., social isolation, loneliness, and bereavement), highlighting the need for accurate assessment and tailored interventions.

Hallucinations, though common in youth and younger adults, are not the preserve of these age groups. Accumulating evidence shows that hallucinatory experiences are also present at surprisingly high rates in healthy older adults in the general community. Furthermore, stigma and misunderstanding of hallucinations, together with ageism, may lead to under-reporting of these experiences by older adults, and misdiagnosis or mismanagement by health and mental health practitioners. Consequently, improved public and professional knowledge is needed about the nature and significance of hallucinations with advancing age. The purpose of this review is to provide a comprehensive overview, and critical analysis, of research on the prevalence, psychosocial, and neurobiological factors associated with hallucinations in people aged 60 years and over. To the best of our knowledge, this is the first review of its kind in the literature. The evidence supports a dynamic conceptualization of hallucinations, in which the emergence of hallucinations is viewed as a balance between the sensory, cognitive, or social impairments accompanying advancing age and the degree to which compensatory processes elicited by these impairments are successful. We briefly summarize the implications of the literature for aged care services and interventions, and stress that far more studies are needed in this important field of research.

Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans

OBJECTIVE

Proton pump inhibitors (PPIs) are widely used, and their use is associated with increased risk of adverse events. However, whether PPI use is associated with excess risk of death is unknown. We aimed to examine the association between PPI use and risk of all-cause mortality.

DESIGN

Longitudinal observational cohort study.

SETTING

US Department of Veterans Affairs.

PARTICIPANTS

Primary cohort of new users of PPI or histamine H2 receptor antagonists (H2 blockers) (n=349 312); additional cohorts included PPI versus no PPI (n=3 288 092) and PPI versus no PPI and no H2 blockers (n=2 887 030).

MAIN OUTCOME MEASURES

Risk of death.

RESULTS

Over a median follow-up of 5.71 years (IQR 5.11-6.37), PPI use was associated with increased risk of death compared with H2 blockers use (HR 1.25, CI 1.23 to 1.28). Risk of death associated with PPI use was higher in analyses adjusted for high-dimensional propensity score (HR 1.16, CI 1.13 to 1.18), in two-stage residual inclusion estimation (HR 1.21, CI 1.16 to 1.26) and in 1:1 time-dependent propensity score-matched cohort (HR 1.34, CI 1.29 to 1.39). The risk of death was increased when considering PPI use versus no PPI (HR 1.15, CI 1.14 to 1.15), and PPI use versus no PPI and no H2 blockers (HR 1.23, CI 1.22 to 1.24). Risk of death associated with PPI use was increased among participants without gastrointestinal conditions: PPI versus H2 blockers (HR 1.24, CI 1.21 to 1.27), PPI use versus no PPI (HR 1.19, CI 1.18 to 1.20) and PPI use versus no PPI and no H2 blockers (HR 1.22, CI 1.21 to 1.23). Among new PPI users, there was a graded association between the duration of exposure and the risk of death.

CONCLUSIONS

The results suggest excess risk of death among PPI users; risk is also increased among those without gastrointestinal conditions and with prolonged duration of use. Limiting PPI use and duration to instances where it is medically indicated may be warranted.

Dietary Supplement Use, Knowledge, and Perceptions Among Student Pharmacists

Objective. To compare dietary supplement use between student pharmacists and the general population, and assess knowledge, attitudes toward use, and dietary supplement effectiveness; and to explore how student pharmacists view their education on dietary supplements. Methods. Paper questionnaires administered to student pharmacists collected data about their use, knowledge, and attitudes of dietary supplements. Use was compared to the 2007 National Health Interview survey findings. Results. Of 179 students who responded, 52% had used at least one dietary supplement in their lifetime versus 25% in the general population. Students perceived supplement label information as unhelpful, research into supplements inadequate, and supplements non-essential to health. Students thought supplement knowledge was important but their education was inadequate. Conclusion. Dietary supplement use was higher in this sample of student pharmacists than the general population. Student pharmacists had limited knowledge and need more education on dietary supplements.

Pharmacologic Considerations of Anesthetic Agents in Geriatric Patients

Aging is a natural process of declining organ function and reserve. Census data show that the geriatric population is expected to grow to nearly 30%. More than half of geriatric patients have 1 or more surgical procedures in their lifetimes. Moreover, this is the population at greatest risk of morbidity and mortality with any given complication. There is remarkable variability in health across the age spectrum, from fit to frail and compromised. This variability requires a unique approach to anesthetic delivery and drug dosing on an individual basis to avoid complications such as postoperative cognitive dysfunction and delirium.

Alcohol, aging, and innate immunity

The global population is aging: in 2010, 8% of the population was older than 65 y, and that is expected to double to 16% by 2050. With advanced age comes a heightened prevalence of chronic diseases. Moreover, elderly humans fair worse after acute diseases, namely infection, leading to higher rates of infection-mediated mortality. Advanced age alters many aspects of both the innate and adaptive immune systems, leading to impaired responses to primary infection and poor development of immunologic memory. An often overlooked, yet increasingly common, behavior in older individuals is alcohol consumption. In fact, it has been estimated that >40% of older adults consume alcohol, and evidence reveals that >10% of this group is drinking more than the recommended limit by the National Institute on Alcohol Abuse and Alcoholism. Alcohol consumption, at any level, alters host immune responses, including changes in the number, phenotype, and function of innate and adaptive immune cells. Thus, understanding the effect of alcohol ingestion on the immune system of older individuals, who are already less capable of combating infection, merits further study. However, there is currently almost nothing known about how drinking alters innate immunity in older subjects, despite innate immune cells being critical for host defense, resolution of inflammation, and maintenance of immune homeostasis. Here, we review the effects of aging and alcohol consumption on innate immune cells independently and highlight the few studies that have examined the effects of alcohol ingestion in aged individuals.

Unused medications and disposal patterns at home: Findings from a Medicare patient survey and claims data

OBJECTIVE

To examine what medications are most frequently left unused by patients, how much is left unused, and how these medications are disposed of among Medicare beneficiaries.

DESIGN

Secondary data analysis combining insurance claims and telephone survey data of Medicare Advantage members.

SETTING

Regional health plan in Central Pennsylvania.

PARTICIPANTS

Seven hundred twenty-one Medicare Advantage members who had Part D coverage through the plan as of December 31, 2013, and completed the telephone survey in May 2014.

INTERVENTION

Telephone survey conducted by a survey research center.

MAIN OUTCOME MEASURE

Member survey response.

RESULTS

Of the 2,994 medications in the dataset, 247 (8%) were reported being left unused by patients. Of the 247, the most common medications were those for pain (15%), hypertension (14%), antibiotics (11%), and psychiatric disorders (9%). Approximately 15% of unused medications were controlled substances. The reasons for being unused varied by drug type. For example, for pain medications, adverse effects and overprescribing were the most commonly cited reasons; for hypertension medications, "dosage changed by doctor" was the most common reason. Most commonly, unused portions accounted for approximately 25% to 50% of the unused medications identified by patients. Approximately 11% of unused medication was disposed of via drug take-back programs, whereas the majority was kept in a cabinet (55%), thrown in the trash (14%), or flushed down the toilet (9%).

CONCLUSION

A lack of patient adherence alone does not explain unused medications and their improper disposal. Community-level interventions designed to improve prescription efficiency and patient awareness of appropriate disposal methods-particularly of controlled substances-are necessary to reduce the potentially harmful effects of improper disposal of unused medications.

Over-the-counter medications containing diphenhydramine and doxylamine used by older adults to improve sleep

Background The unintentional misuse of over-the-counter sleep aids among older adults is an important public health problem and a focus of Healthy People 2020. Accordingly, the 2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults recommends that individuals 65 years or older avoid use of diphenhydramine and doxylamine; however, many over-the-counter sleep products contain these active ingredients. Objective To identify the proportion of older adults using an over-the-counter medication containing diphenhydramine or doxylamine, and compare their characteristics with older adults using an over-the-counter medication that does not contain these ingredients. Setting Study participants were recruited from the Community Registry of the Pittsburgh Claude D. Pepper Older Americans Independence Center. Method The study sample was taken from a larger survey of 1025 participants on sleep health and over-the-counter sleep medication use conducted from February to April 2015. A subset of 169 participants aged 65 and older reporting taking at least one over-the-counter product to improve sleep within the past 30 days (16.5%) were selected for our analysis on associations between participant characteristics and potentially inappropriate use of over-the-counter sleep medications. Main outcome measure The proportion and characteristics of older adults taking at least one over-the-counter medication containing diphenhydramine or doxylamine. Results Of the 223 over-the-counter sleep medications listed by participants, 115 (52%) contained diphenhydramine or doxylamine. Using the Beers Criteria, we found that more than half of participants (59%) had used a potentially inappropriate over-the-counter medication containing diphenhydramine or doxylamine to improve sleep within the past 30 days. Participants taking at least one diphenhydramine or doxylamine containing medication were less likely to be aware of any safety risks in taking over-the-counter sleep medications than participants not taking these products (38 vs 49%, p = 0.016). Conclusion A majority of older adults in a limited sample from the United States taking an over-the-counter medication to improve sleep are taking a product containing diphenhydramine or doxylamine, both of which are classified as potentially inappropriate for older adults. Awareness of the safety risks of over-the-counter medications and addressing conditions that impact sleep quality could be facilitated through consultation with pharmacists and other healthcare providers.

Pharmacokinetics of coadministration of levothyroxine sodium and alendronate sodium new effervescent formulation

No clinically important pharmacokinetic interference of alendronate occurred between a new effervescent formulation of alendronate and levothyroxine when coadministered. The combination does not materially affect levothyroxine absorption.

INTRODUCTION

Concurrent treatment of osteoporosis with alendronate (Aln) and hypothyroidism with levothyroxine (LT4) may be problematic because both drugs are to be taken separately after fasting overnight. The primary objective was to assess pharmacokinetic interactions between a new effervescent formulation of Aln (Aln-NEF) and LT4.

METHODS

A randomized, open-label, 3-way crossover study was conducted in 30 healthy adults (15 women). Subjects were dosed 3 times, separated by 35 days, after overnight fasts, with Aln-NEF alone (70 mg), LT4 alone (600 μg), or Aln-NEF and LT4 concurrently. Samples were analyzed for plasma Aln and serum LT4. Pharmacokinetic drug-drug interaction was assessed using 90% confidence intervals (CIs) for the test/reference ratio of the geometric means for area under the concentration-time curve from time zero to last measureable time point (AUC_0-t ) and maximum concentration (C _max). Results were compared to the default no-effect boundaries of 80 to 125% for the ratio Aln-NEF and LT4 concurrently/Aln-NEF alone and the ratio Aln-NEF and LT4 concurrently/LT4 alone.

RESULTS

Geometric mean ratios (Aln-NEF with LT4/Aln-NEF alone) were 0.927 (90% CI 0.795-1.081) for AUC_0-8 and 0.912 (90% CI 0.773-1.077) for C _max, demonstrating LT4 does not appreciably affect the pharmacokinetics of Aln. Geometric mean ratios (LT4 with Aln-NEF/LT4 alone) were 1.049 (90% CI 0.983-1.119) for AUC_0-48 and 1.075 (90% CI 1.006-1.148) for C _max, demonstrating LT4 is bioequivalent between the 2 treatments. Coadministration of Aln-NEF and LT4 was well tolerated.

CONCLUSIONS

There was no clinically important pharmacokinetic interference between the Aln-NEF formulation and LT4. Aln-NEF does not materially affect LT4 absorption.

Analysis of the variability of the pharmacokinetics of multiple drugs in young adult and elderly subjects and its implications for acceptable daily exposures and cleaning validation limits

The elderly constitute a significant, potentially sensitive, subpopulation within the general population, which must be taken into account when performing risk assessments including determining an acceptable daily exposure (ADE) for the purpose of a cleaning validation. Known differences in the pharmacokinetics of drugs between young adults (who are typically the subjects recruited into clinical trials) and the elderly are potential contributors affecting the interindividual uncertainty factor (UF_H) component of the ADE calculation. The UF_H values were calculated for 206 drugs for young adult and elderly groups separately and combined (with the elderly assumed to be a sensitive subpopulation) from published studies where the pharmacokinetics of the young adult and elderly groups were directly compared. Based on the analysis presented here, it is recommended to use a default UF_H value of 10 for worker populations (which are assumed to be approximately equivalent to the young adult groups) where no supporting pharmacokinetic data exist, while it is recommended to use a default UF_H value of 15 for the general population, to take the elderly into consideration when calculating ADE values. The underlying reasons for the large differences between the exposures in the young adult and elderly subjects for the 10 compounds which show the greatest separation are different in almost every case, involving the OCT2 transporter, glucuronidation, hydrolysis, CYP1A2, CYP2A6, CYP2C19, CYP2D6, CYP3A4 or CYP3A5. Therefore, there is no consistent underlying mechanism which appears responsible for the largest differences in pharmacokinetic parameters between young adult and elderly subjects.

Medication regimen complexity in ambulatory older adults with heart failure

PURPOSE

Heart failure prevalence is increasing in older adults, and polypharmacy is a major problem in this population. We compared medication regimen complexity using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool in "young-old" (60-74 years) versus "old-old" (75-89 years) patients with heart failure. We also compared pMRCI between patients with ischemic cardiomyopathy (ISCM) versus nonischemic cardiomyopathy (NISCM).

PATIENTS AND METHODS

Medication lists were retrospectively abstracted from the electronic medical records of ambulatory patients aged 60-89 years with heart failure. Medications were categorized into three types - heart failure prescription medications, other prescription medications, and over-the-counter (OTC) medications - and scored using the pMRCI tool.

RESULTS

The study evaluated 145 patients (n=80 young-old, n=65 old-old, n=85 ISCM, n=60 NISCM, mean age 73±7 years, 64% men, 81% Caucasian). Mean total pMRCI scores (32.1±14.4, range 3-84) and total medication counts (13.3±4.8, range 2-30) were high for the entire cohort, of which 72% of patients were taking eleven or more total medications. Total and subtype pMRCI scores and medication counts did not differ significantly between the young-old and old-old groups, with the exception of OTC medication pMRCI score (6.2±4 young-old versus 7.8±5.8 old-old, P=0.04). With regard to heart failure etiology, total pMRCI scores and medication counts were significantly higher in patients with ISCM versus NISCM (pMRCI score 34.5±15.2 versus 28.8±12.7, P=0.009; medication count 14.1±4.9 versus 12.2±4.5, P=0.008), which was largely driven by other prescription medications.

CONCLUSION

Medication regimen complexity is high in older adults with heart failure, and differs based on heart failure etiology. Additional work is needed to address polypharmacy and to determine if medication regimen complexity influences adherence and clinical outcomes in this population.

Health care-seeking behaviours and health expenditures in adults aged 45 years and older in China, 2011-2013

OBJECTIVES

To provide an assessment of China's progress to universal health coverage (UHC) from the perspective of people-centred care.

METHODS

We obtained data on 28 103 participants from the China Health and Retirement Longitudinal Study (CHALRS) during 2011-2013. We used logistic regressions and generalised linear models to analyse care-seeking behaviours and medical expenditures.

RESULTS

We found that 95.5% of the subjects were covered by social health insurance in 2013, and nearly 60% subjects in need of medical care were self-medicated. Health insurance was a strong predictor for the access to outpatient care. Use of pure and mixed self-medication increased by 15% and 32% respectively, while use of pure outpatient care fell by 10% between 2011 and 2013, after adjusting for predisposing, service needs and enabling factors. Such trends were particularly evident for the Urban Resident Basic Medical Insurance and the New Cooperative Medical Scheme, which covered more than 80%. The monthly out-of-pocket medical expenditures and the probability of encountering catastrophic health expenditures for outpatient care were four times larger than that for self-medication. Between 2011 and 2013, outpatient care medical costs rose by nearly 50%, whereas there was no such obvious trend for self-medication. People with insurance schemes offering lower cost sharing incurred consistently higher out-of-pocket outpatient payments.

CONCLUSIONS

The monitoring of global progress to UHC should incorporate self-medication. In China, it seems that the current reform and the huge government investment have not resulted in access to affordable quality care. To achieve UHC, not only universal insurance, but system-level efforts are needed.

A survey of attitudes, practices, and knowledge regarding drug-drug interactions among medical residents in Iran

Background When prescribing medications, physicians should recognize clinically relevant potential drug-drug interactions (DDIs). To improve medication safety, it is important to understand prescribers' knowledge and opinions pertaining to DDIs. Objective To determine the current DDI information sources used by medical residents, their knowledge of DDIs, their opinions about performance feedback on co-prescription of interacting drugs. Setting Academic hospitals of Mashhad University of Medical Sciences (MUMS) in Iran. Methods A questionnaire containing questions regarding demographic and practice characteristics, DDI information sources, ability to recognize DDIs, and opinions about performance feedback was distributed to medical residents of 22 specialties in eight academic hospitals in Iran. We analyzed their perception pertaining to DDIs, their performance on classifying drug pairs, and we used a linear regression model to assess the association of potential determinants on their DDI knowledge. Main Outcome Measure prescribers' knowledge and opinions pertaining to DDIs. Results The overall response rate and completion rate for 315 distributed questionnaires were 90% (n = 295) and 86% (n = 281), respectively. Among DDI information sources, books, software on mobile phone or tablet, and Internet were the most commonly-used references. Residents could correctly classify only 41% (5.7/14) of the drug pairs. The regression model showed no significant association between residents' characteristics and their DDI knowledge. An overwhelming majority of the respondents (n = 268, 95.4%) wished to receive performance feedback on co-prescription of interacting drugs in their prescriptions. They mostly selected information technology-based tools (i.e. short text message and email) as their preferred method of receiving feedback. Conclusion Our findings indicate that prescribers may have poor ability to prevent clinically relevant potential DDI occurrence, and they perceive the need for performance feedback. These findings underline the importance of well-designed computerized alerting systems and delivering performance feedback to improve patient safety.

Self-medication among people living with hypertension: a review

BACKGROUND

Self-medication is commonly practised by patients, underpinned by health beliefs that affect their adherence to medication regimens, and impacting on treatment outcomes.

OBJECTIVES

This review explores the scope of self-medication practices among people with hypertension, in terms of the scale of use, types of medication and influencing factors.

METHOD

A comprehensive search of English language, peer-reviewed literature published between 2000 and 2014 was performed. Twenty-seven studies met the inclusion criteria; 22 of these focused on complementary and alternative medicines (CAMs).

RESULTS

Anti-hypertensive medications are listed among the 11% of products that patients reportedly obtain over-the-counter (OTC) for self-medication. On average, 25% of patients use CAMs, mostly herbs, to lower blood pressure. Recommendations by family, friends and neighbours are the most influential factors for self-medication with CAMs. Faith in treatment with CAMs, dissatisfaction with conventional medicine and the desire to reduce medication costs are also cited. Most (70%) patients with hypertension take OTC medicines to treat minor illnesses. The concurrent use of anti-hypertensive medications with analgesics and herbal medicines is commonly practised. The sociodemographic profile of patients engaging in self-medication differs markedly in the articles reviewed; self-medication practices cannot be attributed to a particular profile. Low disclosure of self-medication is consistently reported.

CONCLUSION

This review highlights a high proportion of people with hypertension practise self-medication. Further studies are needed to assess the impact of self-medication with OTC and anti-hypertensive medications on hypertension treatment. Health professionals involved in hypertension management should be mindful of any types of self-medication practices.

Guidance on opioids prescribing for the management of persistent non-cancer pain in older adults

Many older adults suffer from persistent pain but prevalence studies consistently showed high levels of untreated or under-treated pain in old population. Both persistent pain and pain under-treatment adversely affect independence and quality of life in geriatric patients. Pain management is challenging in this age-group because of the declining organ function, the presence of concurrent diseases and polypharmacy. For all the above reasons, persistent pain in the elderly should be considered a geriatric syndrome per se and effective approaches are warranted. Current guidelines and consensus statements recommend opioid therapy for older adults with moderate-to-severe persistent pain or functional impairment and diminished quality of life due to pain. However clinicians and patients themselves have some concerns about opioids use. Age-related decline in organs functions and warnings about risk of addiction and drug misuse/abuse also in geriatric patients need particular attention for safe prescribing. On the basis of clinical evidence, these practical recommendations will help to improve the competence on opioid role in persistent pain management and the likelihood of a successful analgesic trial in older patients.

Variability in medication taking is associated with cognitive performance in nondemented older adults

Interventions to slow cognitive decline typically can do little to reverse decline. Thus, early detection methods are critical. However, tools like cognitive testing are time consuming and require costly expertise. Changes in activities of daily living such as medication adherence may herald the onset of cognitive decline before clinical standards. Here, we determine the relationship between medication adherence and cognitive function in preclinical older adults. We objectively assessed medication adherence in 38 older adults (mean age 86.7 ± 6.9 years). Our results demonstrate that individuals with lower cognitive function have more spread in the timing of taking their medications (P = .014) and increase the spread in the timing of taking their medications over time (P = .012). These results demonstrate that continuous monitoring of medication adherence may provide the opportunity to identify patients experiencing slow cognitive decline in the earliest stages when pharmacologic or behavioral interventions may be most effective.

Patients on psychotropic medications and herbal supplement combinations: clinical considerations

Populations using herbs and herbal preparations are widespread and growing. As many herbal ingredients exert actions on psychotropic drug targets, psychiatrists should be well informed and aware of potential drug-drug interactions in clinical practice. Reliable and clinically useful information in this area, however, is fragmented, if not deficient. This paper reviewed the clinical aspects of herb-drug interactions, focusing in particular on the monoamine oxidase enzyme and P450 cytochrome enzyme-inhibitory properties of herbs and their potential interference with psychotropic drug actions and clinical judgement.

Cytomegalovirus serostatus, inflammation, and antibody response to influenza vaccination in older adults: The moderating effect of beta blockade

Cytomegalovirus (CMV) has been implicated as a factor in immunosenescence, including poor antibody response to vaccination and higher immune activation and inflammation. Some people may be more or less vulnerable to the negative effects of CMV. The present investigation tested the effects of beta-blocker use and chronological age on the associations between CMV and immunity in adults aged 60-91 (N=98; 69% CMV seropositive) who were administered the trivalent influenza vaccine for up to 5years. Peak antibody response, corrected for baseline, and spring (persistent) antibody response, corrected for peak, were assessed, as well as beta-2 microglobulin (β2μ) and interleukin-6 (IL-6). In multi-level models with years at Level 1 and people at Level 2, CMV serostatus did not predict peak antibody response, but there was a 3-way interaction between CMV serostatus, age, and beta-blockers. Age was negatively associated with peak antibody, but only among adults who were CMV seropositive and taking beta-blockers. CMV seronegative adults who were not taking beta-blockers had the highest antibody persistence. CMV serostatus was not associated with β2μ or IL-6. Results suggest that CMV+ serostatus may negatively compromise antibody response to a greater degree than inflammatory markers in older adults. Furthermore, older adults who take beta-blockers may be more vulnerable to negative effects of age and CMV on peak antibody response, perhaps by virtue of their underlying health condition.

Optimizing Medication Use Through Deprescribing: Tactics for This Approach

As older adults age, it is imperative to constantly reevaluate medications. Deprescribing, the process of identifying and discontinuing drugs that could potentially harm rather than benefit a patient, should therefore be considered in all older adults on an individual basis. Nurses are a critical part of the team in addressing this issue. The current article discusses deprescribing, tactics to this approach, and important areas for future development.

Medication use by middle-aged and older participants of an exercise study: results from the Brain in Motion study

Background

Over the past 50 years, there has been an increase in the utilization of prescribed, over-the-counter (OTC) medications, and natural health products. Although it is known that medication use is common among older persons, accurate data on the patterns of use, including the quantity and type of medications consumed in a generally healthy older population from a Canadian perspective are lacking. In this study, we study the pattern of medication use in a sedentary but otherwise healthy older persons use and determined if there was an association between medication use and aerobic fitness level.

Methods

All participants enrolled in the Brain in Motion study provided the name, formulation, dosage and frequency of any medications they were consuming at the time of their baseline assessment. Maximal aerobic capacity (VO₂max) was determined on each participant.

Results

Two hundred seventy one participants (mean age 65.9 ± 6.5 years; range 55–92; 54.6% females) were enrolled. Most were taking one or more (1+) prescribed medication (n = 204, 75.3%), 1+ natural health product (n = 221, 81.5%) and/or 1+ over-the-counter (OTC) drug (n = 174, 64.2%). The most commonly used prescribed medications were HMG-CoA reductase inhibitors (statins) (n = 52, 19.2%). The most common natural health product was vitamin D (n = 201, 74.2%). For OTC drugs, non-steroidal anti-inflammatories (n = 82, 30.3%) were the most common. Females were more likely than males to take 1+ OTC medications, as well as supplements. Those over 65 years of age were more likely to consume prescription drugs than their counterparts (p ≤ 0.05). Subjects taking more than two prescribed or OTC medications were less physically fit as determined by their VO₂max. The average daily Vitamin D intake was 1896.3 IU per participant.

Conclusions

Medication use was common in otherwise healthy older individuals. Consumption was higher among females and those older than 65 years. Vitamin D intake was over two-fold higher than the recommended 800 IU/day for older persons, but within the tolerable upper intake of 4,000 IU/day. The appropriateness of the high rate of medication use in this generally healthy population deserves further investigation.

Clinical impact of pharmacogenetic profiling with a clinical decision support tool in polypharmacy home health patients: A prospective pilot randomized controlled trial

BACKGROUND

In polypharmacy patients under home health management, pharmacogenetic testing coupled with guidance from a clinical decision support tool (CDST) on reducing drug, gene, and cumulative interaction risk may provide valuable insights in prescription drug treatment, reducing re-hospitalization and emergency department (ED) visits. We assessed the clinical impact of pharmacogenetic profiling integrating binary and cumulative drug and gene interaction warnings on home health polypharmacy patients.

METHODS AND FINDINGS

This prospective, open-label, randomized controlled trial was conducted at one hospital-based home health agency between February 2015 and February 2016. Recruitment came from patient referrals to home health at hospital discharge. Eligible patients were aged 50 years and older and taking or initiating treatment with medications with potential or significant drug-gene-based interactions. Subjects (n = 110) were randomized to pharmacogenetic profiling (n = 57). The study pharmacist reviewed drug-drug, drug-gene, and cumulative drug and/or gene interactions using the YouScript® CDST to provide drug therapy recommendations to clinicians. The control group (n = 53) received treatment as usual including pharmacist guided medication management using a standard drug information resource. The primary outcome measure was the number of re-hospitalizations and ED visits at 30 and 60 days after discharge from the hospital. The mean number of re-hospitalizations per patient in the tested vs. untested group was 0.25 vs. 0.38 at 30 days (relative risk (RR), 0.65; 95% confidence interval (CI), 0.32-1.28; P = 0.21) and 0.33 vs. 0.70 at 60 days following enrollment (RR, 0.48; 95% CI, 0.27-0.82; P = 0.007). The mean number of ED visits per patient in the tested vs. untested group was 0.25 vs. 0.40 at 30 days (RR, 0.62; 95% CI, 0.31-1.21; P = 0.16) and 0.39 vs. 0.66 at 60 days (RR, 0.58; 95% CI, 0.34-0.99; P = 0.045). Differences in composite outcomes at 60 days (exploratory endpoints) were also found. Of the total 124 drug therapy recommendations passed on to clinicians, 96 (77%) were followed. These findings should be verified with additional prospective confirmatory studies involving real-world applications in larger populations to broaden acceptance in routine clinical practice.

CONCLUSIONS

Pharmacogenetic testing of polypharmacy patients aged 50 and older, supported by an appropriate CDST, considerably reduced re-hospitalizations and ED visits at 60 days following enrollment resulting in potential health resource utilization savings and improved healthcare.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02378220.

Psychosocial Correlates of Dietary Supplement Use: Results from the National Survey of Midlife Development in the United States

Drawing on data gathered in the National Survey of Midlife Development in the United States, this study examined internal and external locus of control, self-esteem, neuroticism, perceived health status, uniqueness, and somatic amplification as correlates of dietary supplement use. With sex, race, and age measures also included in the study, bivariate analyses showed greater supplement use among women and older respondents as well as those scoring higher on internal locus of control, self-esteem, perceived health status, and somatic amplification. Regression analyses identified sex and internal locus of control as the strongest predictors. Interactions between age and external locus of control also emerged.

Improving over-the-counter medication safety for older adults: A study protocol for a demonstration and dissemination study

BACKGROUND

Adverse drug events (ADEs) associated with over-the-counter (OTC) medications cause 178,000 hospitalizations each year. Older adults, aged 65 and older, are particularly vulnerable to ADEs. Of the 2.2 million older adults considered at risk for a major ADE, more than 50% are at risk due to concurrent use of an OTC and prescription medication.

OBJECTIVES

To refine the intervention and implementation strategy through diagnostic and formative evaluation; to evaluate the effectiveness of the intervention for preventing misuse of high-risk OTC medications by older adults; and to evaluate the implementation of the intervention in community pharmacies.

METHODS

A system redesign intervention to decrease high-risk OTC medication misuse will be tested to reduce misuse by improving communication between older adults and community pharmacists via the following features: a redesign of the physical environment to sensitize older adults to high-risk OTC medications, and the implementation of a clinical decision tool to support the pharmacist when critically evaluating the older adult's health status. The study will be conducted in three phases: a participatory design phase, a beta phase, and a test phase. The test phase will be conducted in three mass-merchandise stores. A total of 144 older adults will be recruited. A pre (control)/post (intervention) test will determine the effectiveness of the intervention. The primary outcome will be a comparison of proportion of older adults who misuse OTC medication from baseline to post-intervention. The process of implementation in the community pharmacy setting will be evaluated using the taxonomy proposed by Proctor et al. The participatory design phase has been approved by the institution's IRB (2016-0743).

PROJECTED IMPACT

It is anticipated that this project, which focuses on achieving systems-based improvement in an underemphasized area of the medication use process, will reduce ADEs associated with inappropriate OTC medication use in older adults.

Osteopathic Manipulative Treatment for Older Patients: A National Survey of Osteopathic Physicians

CONTEXT

The mission of the American Academy of Osteopathy (AAO) emphasizes "the integration of osteopathic principles, practices and manipulative treatment in patient care." Osteopathic manipulative treatment (OMT) can be used to address serious conditions affecting older persons (≥65 years). However, the percentage of osteopathic physicians who use OMT in older patients, the differences in conditions for which OMT is used, and the OMT techniques used in older patients compared with younger patients are unknown.

OBJECTIVE

To determine the use of OMT by osteopathic physicians in older patients compared with younger patients.

METHODS

Members of the AAO were invited, via 3 e-mail messages sent over the course of a 4-month period, to participate in an anonymous online survey. The survey asked physicians to report the percentage of patients by age group (<65 years, 65-79 years, and ≥80 years) to whom they provided OMT, the types of musculoskeletal and system-based conditions for which OMT was used, and the specific OMT techniques used.

RESULTS

A total of 197 of 629 AAO members (31.3%) responded to the survey. Respondents indicated that OMT was used at approximately the same rate in all patients in the 3 age groups. Osteopathic manipulative treatment was frequently used to manage a variety of musculoskeletal conditions, with the exception of osteoporosis, in all patients in the 3 age groups. The system-based conditions most often managed with OMT were respiratory and neurologic conditions. Various OMT techniques were used to treat patients in the 3 age groups; however, high-velocity, low-amplitude (HVLA) was usually avoided in patients aged 65 years or older.

CONCLUSION

Osteopathic physicians who used OMT in their practice administered OMT for a variety of musculoskeletal and system-based conditions in patients of all ages. Various OMT techniques were used by these physicians for patients of all ages, with the exception of HVLA, which was mainly used in patients younger than 65 years.

Awareness and knowledge among internal medicine house-staff for dose adjustment of commonly used medications in patients with CKD

Background

Drug dosing errors result in adverse patient outcomes and are more common in patients with chronic kidney disease (CKD). As internists treat the majority of patients with CKD, we study if Internal Medicine house-staff have awareness and knowledge about the correct dosage of commonly used medications for those with CKD.

Methods

A cross-sectional survey was performed and included 341 participants. The outcomes were the awareness of whether a medication needs dose adjustment in patients with CKD and whether there was knowledge for the level of glomerular filtration rate (GFR) a medication needs to be adjusted.

Results

The overall pattern for all post-graduate year (PGY) groups in all medication classes was a lack of awareness and knowledge. For awareness, there were statistically significant increased mean differences for PGY2 and PGY3 as compared to PGY1 for allergy, endocrine, gastrointestinal, and rheumatologic medication classes but not for analgesic, cardiovascular, and neuropsychotropic medication classes. For knowledge, there were statistically significant increased mean differences for PGY2 and PGY3 as compared to PGY1 for allergy, cardiovascular, endocrine, and gastrointestinal, medication classes but not for analgesic, neuropsychotropic, and rheumatologic medication classes.

Conclusions

Internal Medicine house-staff across all levels of training demonstrated poor awareness and knowledge for many medication classes in CKD patients. Internal Medicine house-staff should receive more nephrology exposure and formal didactic educational training during residency to better manage complex treatment regimens and prevent medication dosing errors.

Driving performance comparing older versus younger drivers

OBJECTIVES

A cross-sectional study was conducted at the Touro University California campus to compare differences in reaction times and driving performance of younger adult drivers (18-40 years) and older adult drivers (60 years and older). Each test group consisted of 38 participants.

METHODS

A Simple Visual Reaction Test (SVRT) tool was used to measure reaction times. The STISIM Drive M100 driving simulator was used to assess driving parameters. Driving performance parameters included mean lane position, standard deviation of mean lane position measured, mean speed, standard deviation of mean speed, car-following delay, car-following modulus, car-following coherence, off-road accidents, collisions, pedestrians hit, and traffic light tickets.

RESULTS

Compared to younger participants, older drivers experienced significantly slower reaction times (510.0 ± 208.8 vs. 372.4 ± 96.1 ms, P =.0004), had more collisions (0.18 ± 0.39 vs. none, P =.0044), drove slower (44.6 ± 6.6 vs. 54.9 ± 11.7 mph, P <.0001), deviated less in speed (12.6 ± 4.3 vs. 16.8 ± 6.3, P =.0011), and were less able to maintain a constant distance behind a pace car (0.42 ± 0.23 vs. 0.59 ± 0.24; P =.0025).

CONCLUSIONS

Differences exist in driving patterns of older and younger drivers as measured by reaction times and driving simulator outcomes. These results are the first to compare these 2 specific adult age groups' driving performance as measured by a standardized driving simulator scenario. Identifying these differences is essential in addressing them and preventing future traffic injuries.

Potentially inappropriate medications prescribed for elderly patients through family physicians

The elderly population is increasing throughout the globe, resulting in higher healthcare costs. Potential inappropriate medication (PIM) prescriptions are a major health problem affecting the elderly persons. Due to limited studies in PIM use in primary care and home healthcare in Saudi Arabia, we aim to examine the extent of PIM prescription for and use by elderly patients. This study was carried out with 798 elderly patients, arbitrarily selected from Prince Sultan Medical Military City through the patient register. The mean age of the patients were in the range of 75.2 ± 5.5; 37.8% were males and 62.2% were females. The elderly patients are affected majorly with diabetes (73.9%), hypertension (83.2%) and lipid abnormalities (73.8%). The maximum patients involved in this study were affected with lower hemoglobin levels i.e. 99.2%. Renal impairment was found in 64% and iron supplements were the most commonly used in 23.1%, followed by analgesics and opioids (17%). The 52.5% of participants were using one or more PIMs. Kidney was the only functions and had influence on prescribed decisions. This study indicates PIM is a concern in elderly patients attending clinics and home residents and commonly prescribed ones are atypical antipsychotics, iron overdose, benzodiazepines and opioids. Prescription of drug-drug interactions, cascades and inappropriate drug doses results in preventable adverse effects.

Deprescribing: a primary care perspective

Polypharmacy is an increasing and global issue affecting primary care. Although sometimes appropriate, polypharmacy can also be problematic, leading to a range of adverse consequences. Deprescribing is the process of supervised withdrawal of an inappropriate medication and has the potential to reduce some of the problems associated with polypharmacy. It is a complex and sensitive process. We examine the issue of deprescribing from the perspective of primary care. Key steps in the deprescribing process are a review of medications and corresponding indications, consideration of harms, assessment of eligibility for discontinuation, prioritisation of medications and implementation of a stopping plan with appropriate monitoring. Patient involvement is a key feature of this process. Deprescribing should be considered in the context of end-of-life care and medication safety, but approaches are also required to identify other situations where deprescribing is appropriate. General practitioners are well positioned to facilitate deprescribing, usually through formal medication review, with decisions informed by a range of other healthcare professionals. Guidelines are available that help guide these processes. A range of studies have explored attitudes towards deprescribing; patients are generally supportive of the concept, although clinician views are varied. The successful implementation of deprescribing strategies still requires important patient and clinician barriers to be overcome, and clinical trial evidence of effectiveness and safety is essential.

Memory for medication side effects in younger and older adults: the role of subjective and objective importance

Older adults often experience memory impairments, but sometimes they can use selective processing and schematic support to remember important information. In the present experiments, we investigated the degrees to which younger and healthy older adults remembered medication side effects that were subjectively or objectively important to remember. Participants studied a list of common side effects and rated how negative these effects would be if they were to experience them, and they were then given a free recall test. In Experiment 1, the severity of the side effects ranged from mild (e.g., itching) to severe (e.g., stroke), and in Experiment 2, certain side effects were indicated as being critical to remember (i.e., "contact your doctor if you experience this"). We observed no age differences in terms of free recall of the side effects, and older adults remembered more severe side effects than mild effects. However, older adults were less likely to recognize the critical side effects on a later recognition test, relative to younger adults. These findings suggest that older adults can selectively remember medication side effects but have difficulty identifying familiar but potentially critical side effects, and this has implications for monitoring medication use in older age.

Herbal medications and other dietary supplements. A clinical review for physicians caring for older people

Evidence for the safety and effectiveness of dietary supplements is mixed. The extent to which older people use dietary supplements concomitantly with conventional medications is often under-appreciated by physicians. We conducted a literature review on clinical considerations associated with dietary supplement use, focusing on benefits and harms, motivations for use and contribution to polypharmacy among older people. Vitamin D ≥ 800 IU has demonstrated benefits in fracture prevention. Vitamins A, E, and β-carotene have been associated with an increase in total mortality in several meta-analyses. A range of non-vitamin dietary supplements have been studied in randomized controlled trials but their efficacy remains largely unclear. Supplement use has been associated with a range of adverse events and drug interactions yet physicians rarely initiate discussions about their use with older patients. Older people may take dietary supplements to exercise control over their health. Given the contribution of supplements to polypharmacy, supplements may be targeted for "deprescribing" if the risk of harm is judged to outweigh benefits. This is best done as part of a comprehensive, patient-centered approach. A respectful and non-judgmental discussion may result in a shared decision to reduce polypharmacy through cessation of dietary supplements. KEY MESSAGES Herbal medications and other dietary supplements are highly prevalent among older people. Physicians are often unaware that their patients use herbal medications and other dietary supplements concomitantly with conventional medications. Herbal medications and other dietary supplements contribute to high rates of polypharmacy, particularly among older people with multimorbidity. Herbal medications and other dietary supplements can interact with conventional medications and be associated with a range of adverse events. Physicians need to be patient-centered and non-judgmental when initiating discussions about herbal medications and other dietary supplements. This is important to maintain and develop patient empowerment and self-management skills.

Diuretic Use and Risk of Vertebral Fracture in Women

BACKGROUND

Vertebral fracture is the most common type of osteoporotic fracture. While thiazide diuretics, which are commonly prescribed for the treatment of hypertension, decrease calciuria, they may also induce hyponatremia, which has been associated with increased vertebral fracture risk. Loop diuretics increase calciuria, which would reduce bone mineral density and increase vertebral fracture risk, but they rarely cause hyponatremia. Recent studies on diuretics and fractures did not include or specifically examine vertebral fracture. The few studies of diuretics and vertebral fracture have been limited by cases defined by self-report or administrative data, relatively small number of cases, study design that was not prospective, and lack of long-term follow-up with updated information on diuretic use.

METHODS

We conducted a prospective cohort study of thiazide diuretic use, loop diuretic use, and risk of incident clinical vertebral fracture in 55,780 women, 55-82 years of age, participating in the Nurses' Health Study, without a prior history of any fracture. Diuretic use was assessed by questionnaire every 4 years. Self-reported vertebral fracture was confirmed by medical record review. Cox proportional-hazards models were used to simultaneously adjust for potential confounders.

RESULTS

Our analysis included 420 incident vertebral fracture cases documented between 2002 and 2012. The multivariate-adjusted relative risk of clinical vertebral fracture for women taking thiazides compared with women not taking thiazides was 1.47 (95% confidence interval, 1.18-1.85). The multivariate adjusted relative risk of vertebral fracture for women taking loop diuretics compared with women not taking loop diuretics was 1.59 (95% confidence interval, 1.12-2.25).

CONCLUSION

Thiazide diuretics and loop diuretics are each independently associated with increased risk of vertebral fracture in women.

Characterization of drug and alcohol use among senior drivers fatally injured in U.S. motor vehicle collisions, 2008-2012

OBJECTIVE

Adults 65 years of age and older comprise the fastest growing demographic in the United States. As substance use is projected to increase in this population, there is concern that more seniors will drive under the influence of impairing drugs. The purpose of this analysis was to characterize the drug and alcohol usage among senior drivers fatally injured (FI) in traffic collisions.

METHODS

Data from the Fatality Analysis Reporting System were analyzed from 2008 to 2012. Commonly used classes and specific drugs were explored. Rates of drug use, multiple drugs, concomitant drug and alcohol use, and alcohol use alone were generated using Poisson regression with robust error variance estimation. Rates were compared to a reference population of FI middle-aged drivers (30 to 50 years old) using rate ratios.

RESULTS

Drug use among FI senior drivers occurred in 20.0% of those tested. Among drug-positive FI senior drivers, narcotics and depressants were frequent. The prevalence of testing positive for any drug, multiple drugs, combined drug and alcohol, and alcohol use alone among FI seniors were 47% less (relative risk [RR] = 0.53, 95% confidence interval [CI], 0.47, 0.62), 59% less (RR = 0.41, 95% CI, 0.34, 0.51), 87% less (RR = 0.13, 95% CI, 0.09, 0.19), and 77% less (RR = 0.23, 95% CI, 0.19, 0.28), respectively, compared to FI middle-aged drivers.

CONCLUSIONS

Though overall drug use is less common among FI senior drivers relative to FI middle-aged drivers, driving under the influence of drugs may be a relevant traffic safety concern in a portion of this population.

Gastrointestinal bleeding and intracranial hemorrhage in concomitant users of warfarin and antihyperlipidemics

BACKGROUND

Drug interactions, particularly those involving warfarin, are a major clinical and public health problem. Minimizing serious bleeding caused by anticoagulants is a recent major focus of the United States (US) Department of Health and Human Services. This study quantified the risk of gastrointestinal bleeding (GIB) and intracranial hemorrhage (ICH) among concomitant users of warfarin and individual antihyperlipidemics.

METHODS

The authors conducted a high-dimensional propensity score-adjusted cohort study of new concomitant users of warfarin and an antihyperlipidemic, among US Medicaid beneficiaries from five states during 1999-2011. Exposure was defined by concomitant use of warfarin plus one of eight antihyperlipidemics. The primary outcome measure was a composite of GIB/ICH within the first 30days of concomitant use. As a secondary outcome measure, GIB/ICH was examined within the first 180days of concomitant use.

RESULTS

Among 236,691 persons newly-exposed to warfarin and an antihyperlipidemic, the crude incidence of GIB/ICH was 13.2 (95% confidence interval 12.7 to 13.8) per 100person-years. Users were predominantly older, female, and Caucasian. Adjusted hazard ratios (aHRs) for warfarin and individual statins were consistent with no association. Warfarin+gemfibrozil was associated with an 80% increased risk of GIB/ICH within the first month of concomitant use (aHR=1.8, 1.4 to 2.4). Warfarin+fenofibrate was associated with a similar increased risk (aHR=1.8, 1.2 to 2.7), yet with an onset during the second month of concomitant use.

CONCLUSIONS

Among warfarin-treated persons, the use of fibrates-but not statins-increases the risk of hospital presentation for GIB/ICH.