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

Medical Schools' Industry Interaction Policies Not Associated With Trainees' Self-Reported Behavior as Residents: Results of a National Survey

BACKGROUND

Medical students attending schools with policies limiting industry/student interactions report fewer relationships with pharmaceutical representatives.

OBJECTIVE

To investigate whether associations between students' medical school policies and their more limited industry interaction behaviors persist into residency.

METHODS

We randomly sampled 1800 third-year residents who graduated from 120 allopathic US-based medical schools, using the American Medical Association Physician Masterfile. We surveyed them in 2011 to determine self-reported behavior and preferences for brand-name prescriptions, and we calculated the strength of their medical schools' industry interaction policies using the 2008 American Medical Student Association and Institute on Medicine as a Profession databases. We used logistic regression to estimate the association between strength of school policies and residents' behaviors with adjustments for class size, postresidency career plan, and concern about medical school debt.

RESULTS

We achieved a 44% survey response rate (n = 739). Residents who graduated from schools with restrictive policies were no more or less likely to accept industry gifts or industry-sponsored meals, speak with marketing representative about drug products, attend industry-sponsored lectures, or prefer brand-name medications than residents who graduated from schools with less restrictive policies. Residents who correctly answered evidence-based prescription questions were about 30% less likely to have attended industry-sponsored lectures (OR = 0.72, 95% CI 0.56-0.98).

CONCLUSIONS

Any effect that medical school industry interaction policies had on insulating students from pharmaceutical marketing did not persist in the behavior of residents in our sample. This suggests that residency training environments are important in influencing behavior.

Time trends in 20 years of medication use in older adults: Findings from three elderly cohorts in Stockholm, Sweden

New drugs and expanded drug indications are constantly being introduced. Welfare states strive to provide equity in drug treatment for all of its citizens and todaýs healthcare systems spend financial resources on drugs for the elderly in a higher rate than for any other age group. Drug utilization in elderly persons has an impact in health and wellbeing in older people.

THE PURPOSE OF THE RESEARCH

It was to describe the changes in medication use including people aged 78 years and over regardless of residence and other characteristics over 20 years.

MATERIALS AND METHODS

The study population consisted of 4304 participants in three population-based cross-sectional surveys conducted in the Kungsholmen area of central Stockholm, Sweden. The participant's current drug utilization was reviewed by physicians following standardized protocols. Data were statistical analyzed. Logistic regression models was used to estimate odds ratios and 95% confidence intervals for use of analgesics and psychotropic drugs in the cohorts of 2001 and 2007, controlling for age, gender, education and cognition.

THE PRINCIPAL RESULTS AND MAJOR CONCLUSIONS

Results shows that the prevalence of medication use and polypharmacy in older adults has increased dramatically the late 1980s to the 2000s in central Stockholm, Sweden. In particular, the use of analgesics increased significantly, while some drug groups decreased, i.e., antipsychotics. Women used more medication than men in all three cohorts. Older adults living in service buildings used the largest amount of drugs in 1987, whereas those living in institutions were the most frequent users in 2001 and 2007.

Trends in rates of acetaminophen-related adverse events in the United States

PURPOSE

The goal of this study is to summarize trends in rates of adverse events attributable to acetaminophen use, including hepatotoxicity and mortality.

METHODS

A comprehensive analysis of data from three national surveillance systems estimated rates of acetaminophen-related events identified in different settings, including calls to poison centers (2008-2012), emergency department visits (2004-2012), and inpatient hospitalizations (1998-2011). Rates of acetaminophen-related events were calculated per setting, census population, and distributed drug units.

RESULTS

Rates of poison center calls with acetaminophen-related exposures decreased from 49.5/1000 calls in 2009 to 43.5/1000 calls in 2012. Rates of emergency department visits for unintentional acetaminophen-related adverse events decreased from 58.0/1000 emergency department visits for adverse drug events in 2009 to 50.2/1000 emergency department visits in 2012. Rates of hospital inpatient discharges with acetaminophen-related poisoning decreased from 119.8/100 000 hospitalizations in 2009 to 108.6/100 000 hospitalizations in 2011. After 2009, population rates of acetaminophen-related events per 1 million census population decreased for poison center calls and hospitalizations, while emergency department visit rates remained stable. However, when accounting for drug sales, the rate of acetaminophen-related events (per 1 million distributed drug units) increased after 2009. Prior to 2009, the rates of acetaminophen-related hospitalizations had been slowly increasing (p-trend = 0.001).

CONCLUSIONS

Acetaminophen-related adverse events continue to be a public health burden. Future studies with additional time points are necessary to confirm trends and determine whether recent risk mitigation efforts had a beneficial impact on acetaminophen-related adverse events. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Trends in Prescription Drug Use Among Adults in the United States From 1999-2012

IMPORTANCE

It is important to document patterns of prescription drug use to inform both clinical practice and research.

OBJECTIVE

To evaluate trends in prescription drug use among adults living in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Temporal trends in prescription drug use were evaluated using nationally representative data from the National Health and Nutrition Examination Survey (NHANES). Participants included 37,959 noninstitutionalized US adults, aged 20 years and older. Seven NHANES cycles were included (1999-2000 to 2011-2012), and the sample size per cycle ranged from 4861 to 6212.

EXPOSURES

Calendar year, as represented by continuous NHANES cycle.

MAIN OUTCOMES AND MEASURES

Within each NHANES cycle, use of prescription drugs in the prior 30 days was assessed overall and by drug class. Temporal trends across cycles were evaluated. Analyses were weighted to represent the US adult population.

RESULTS

Results indicate an increase in overall use of prescription drugs among US adults between 1999-2000 and 2011-2012 with an estimated 51% of US adults reporting use of any prescription drugs in 1999-2000 and an estimated 59% reporting use of any prescription drugs in 2011-2012 (difference, 8% [95% CI, 3.8%-12%]; P for trend <.001). The prevalence of polypharmacy (use of ≥5 prescription drugs) increased from an estimated 8.2% in 1999-2000 to 15% in 2011-2012 (difference, 6.6% [95% CI, 4.4%-8.2%]; P for trend <.001). These trends remained statistically significant with age adjustment. Among the 18 drug classes used by more than 2.5% of the population at any point over the study period, the prevalence of use increased in 11 drug classes including antihyperlipidemic agents, antidepressants, prescription proton-pump inhibitors, and muscle relaxants.

CONCLUSIONS AND RELEVANCE

In this nationally representative survey, significant increases in overall prescription drug use and polypharmacy were observed. These increases persisted after accounting for changes in the age distribution of the population. The prevalence of prescription drug use increased in the majority of, but not all, drug classes.

Drug-Alcohol Interactions in Older U.S. Adults

OBJECTIVES

To characterize the extent and nature of drug-alcohol interactions in older U.S. adults.

DESIGN

Cross-sectional.

SETTING

Community.

PARTICIPANTS

Nationally representative population-based sample of community-dwelling older adults (N = 2,975).

MEASUREMENTS

Regular drinkers were defined as respondents who consumed alcohol at least weekly. Medication use was defined as the use of a prescription or nonprescription medication or dietary supplement at least daily or weekly. Micromedex was used to determine drug interactions with alcohol and their corresponding severity.

RESULTS

One thousand one hundred six (41%) of the participants consumed alcohol regularly, and 567 (20%) were at-risk for a drug-alcohol interaction because they were regular drinkers and concurrently using alcohol-interacting medications. More than 90% of these interactions were of moderate or major severity. Antidepressants and analgesics were the most commonly used alcohol-interacting medications in regular drinkers. Older adult men with multiple chronic conditions had the highest prevalence of potential drug-alcohol interactions.

CONCLUSION

The potential for drug-alcohol interactions in the older U.S. adult population may have important clinical implications. Efforts to better understand and prevent the use of alcohol-interacting medications by regular drinkers, particularly heavy drinkers, are warranted in this population.

An overview of appetite decline in older people

Poor appetite is a common problem in older people living at home and in care homes, as well as hospital inpatients. It can contribute to weight loss and nutritional deficiencies, and associated poor healthcare outcomes, including increased mortality. Understanding the causes of reduced appetite and knowing how to measure it will enable nurses and other clinical staff working in a range of community and hospital settings to identify patients with impaired appetite. A range of strategies can be used to promote better appetite and increase food intake.

A Meta-analysis of the Association of Estimated GFR, Albuminuria, Age, Race, and Sex With Acute Kidney Injury

BACKGROUND

Acute kidney injury (AKI) is a serious global public health problem. We aimed to quantify the risk of AKI associated with estimated glomerular filtration rate (eGFR), albuminuria (albumin-creatinine ratio [ACR]), age, sex, and race (African American and white).

STUDY DESIGN

Collaborative meta-analysis.

SETTING & POPULATION

8 general-population cohorts (1,285,049 participants) and 5 chronic kidney disease (CKD) cohorts (79,519 participants).

SELECTION CRITERIA FOR STUDIES

Available eGFR, ACR, and 50 or more AKI events.

PREDICTORS

Age, sex, race, eGFR, urine ACR, and interactions.

OUTCOME

Hospitalized with or for AKI, using Cox proportional hazards models to estimate HRs of AKI and random-effects meta-analysis to pool results.

RESULTS

16,480 (1.3%) general-population cohort participants had AKI over a mean follow-up of 4 years; 2,087 (2.6%) CKD participants had AKI over a mean follow-up of 1 year. Lower eGFR and higher ACR were strongly associated with AKI. Compared with eGFR of 80mL/min/1.73m(2), the adjusted HR of AKI at eGFR of 45mL/min/1.73m(2) was 3.35 (95% CI, 2.75-4.07). Compared with ACR of 5mg/g, the risk of AKI at ACR of 300mg/g was 2.73 (95% CI, 2.18-3.43). Older age was associated with higher risk of AKI, but this effect was attenuated with lower eGFR or higher ACR. Male sex was associated with higher risk of AKI, with a slight attenuation in lower eGFR but not in higher ACR. African Americans had higher AKI risk at higher levels of eGFR and most levels of ACR.

LIMITATIONS

Only 2 general-population cohorts could contribute to analyses by race; AKI identified by diagnostic code.

CONCLUSIONS

Reduced eGFR and increased ACR are consistent strong risk factors for AKI, whereas associations of AKI with age, sex, and race may be weaker in more advanced stages of CKD.

Aging, Genetic Variations, and Ethnopharmacology: Building Cultural Competence Through Awareness of Drug Responses in Ethnic Minority Elders

Unique drug responses that may result in adverse events are among the ethnocultural differences described by the Agency for Healthcare Research and Quality. These differences, often attributed to a lack of adherence on the part of the older adult, may be linked to genetic variations that influence drug responses in different ethnic groups. The paucity of research coupled with a lack of knowledge among health care providers compound the problem, contributing to further disparities, especially in this era of personalized medicine and pharmacogenomics. This article examines how age-related changes and genetic differences influence variations in drug responses among older adults in unique ethnocultural groups. The article starts with an overview of age-related changes and ethnopharmacology, moves to describing genetic differences that affect drug responses, with a focus on medications commonly prescribed for older adults, and ends with application of these issues to culturally congruent health care.

Endodontics and the ageing patient

Patients are living longer and the rate of edentulism is decreasing. Endodontic treatment is an essential part of maintaining the health and well-being of the elderly. Retention of natural teeth improves the quality of life and the overall health and longevity of ageing patients. Also, teeth that might be otherwise extracted may be strategically valuable to retain a prosthesis, and elderly patients are more likely to have medical complications that may prevent dental extractions from being safely performed. The technical goals of endodontic treatment in the elderly are the same as those for younger patients. However, the pulpo-dentinal complex undergoes calcific changes over time, which may pose challenges for the clinician. The purposes of this review are to discuss age changes in the pulp and the challenges posed by diagnosing, treatment planning and treating the elderly endodontic patient.

[Use and potential risks of over-the-counter analgesics]

BACKGROUND AND AIM

We investigated the use of prescription and non-prescription (over-the-counter, OTC) analgesics and the associated risks in elderly patients with multiple morbidities.

METHODS

Pain medication use was evaluated from the baseline data (2008/2009) of the MultiCare cohort enrolling elderly patients with multiple morbidities who were treated by primary care physicians (trial registration: ISRCTN89818205). We considered opioids (N02A), other analgesics, and antipyretics (N02B) as well as nonsteroidal anti-inflammatory drugs (NSAIDs; M01A). OTC use, duplicate prescription, dosages, and interactions were examined for acetylsalicylic acid, diclofenac, (dex)ibuprofen, naproxen, and acetaminophen.

RESULTS

Of 3,189 patients with multiple morbidities aged 65-85 years, 1,170 patients reported to have taken at least one prescription or non-prescription analgesic within the last 3 months (36.7 %). Of these, 289 patients (24.7 % of 1,170) took at least one OTC analgesic. Duplicate prescription was observed in 86 cases; 15 of these cases took the analgesics regularly. In two cases, the maximum daily dose of diclofenac was exceeded due to duplicate prescription. In 235 cases, patients concurrently took a drug with a potentially clinically relevant interaction. In 43 cases (18.3 % of 235) an OTC analgesic, usually ibuprofen, was involved.

DISCUSSION

About one third of the elderly patients took analgesics regularly or as needed. Despite the relatively high use of OTC analgesics, the proportions of duplicate prescription, medication overdoses, and adverse interactions due to OTC products was low.

Geriatric Disaster Preparedness

Introduction

The elderly population has proven to be vulnerable in times of a disaster. Many have chronic medical problems for which they depend on medications or medical equipment. Some older adults are dependent on caregivers for managing their activities of daily living (ADLs), such as dressing, and their instrumental activities of daily living (IADLs), such as transportation.

Problem

A coordinated effort for disaster preparation in the elderly population is paramount. This study assessed the potential needs and plans of older adults in the face of a local disaster.

Methods

The setting was a community-based, university-affiliated, urban emergency department (ED) that sees more than 77,000 adult patients per year. A survey on disaster plans and resources needed if evacuated was distributed to 100 community-residing ED patients and visitors aged 65 years and older from January through July 2013. Means and proportions are reported with 95% confidence intervals (CIs).

Results

Data were collected from 13 visitors and 87 patients. The mean age was 76 years, and 54% were female. Thirty-one responded that they had a disaster plan in place (31/100; CI, 22.4-41.4%). Of those 31, 94% (29/31; CI, 78.6-99.2%) had food and water as part of their plan, 62% (19/29; CI, 42.2-78.2%) had a supply of medication, and 35% (12/31; CI, 21.8-57.8%) had an evacuation plan. When asked what supplies the 100 subjects might need if evacuated, 33% (CI, 23.9-43.1%) needed a walker, 15% (CI, 8.6-23.5%) needed a wheelchair, 78% (CI, 68.6-85.7%) needed glasses, 17% (CI, 10.2-25.8%) needed a hearing aid, 16% (CI, 9.4-24.7%) needed a glucometer, 93% (CI, 86.1-97.1%) needed medication, 14% (CI, 7.8-22.4%) needed oxygen, 23% (CI, 15.2-32.5%) needed adult diapers, and 21% (CI, 13.2-30.3%) had medical equipment that required electricity. Many of the subjects also required help with one or more of their ADLS, the most common being dressing (17%; CI, 10.3-26.1%), or their IADLS, the most common being transportation (39%; CI, 29.7-49.7%). Only 42% (CI, 32.3-52.7%) were interested in learning more about disaster preparation.

Conclusion

Only a minority of the older adults in the study population had a disaster plan in place. Most of the respondents would require medications, and many would require medical supplies if evacuated.

BhallaMC, BurgessA, FreyJ, HardyW. Geriatric disaster preparedness. Prehosp Disaster Med. 2015;30(5):443–446.

Online Education for Improving Communication and Documentation of Dietary Supplements Among Health Professionals Practicing in a Hospital Setting

BACKGROUND

Little is known about the feasibility of online education in improving communication and documentation of dietary supplements (DS) among clinicians.

METHODS

This prospective educational study included clinicians at an urban teaching hospital. The curriculum included video streams, didactics, and interactive case presentations to discuss (1) DS safety and effectiveness, (2) cultural competency, (3) managing DS in a hospital setting, and (4) DS adverse events. Participants were surveyed, at baseline and after training, about DS knowledge, confidence, communication, and documentation practices.

RESULTS

Thirty-nine of 61 (64%) recruited clinicians completed all four patient cases and post-tests. Most (82%) were women and 59% were physicians. The mean DS knowledge test score increased after the curriculum (p < 0.0001), and the clinician confidence score also increased (p < 0.0001). Most (82%) participants reported that curriculum changed their use of evidence-based resources (p = 0.01). There was a change in the indications for symptom management (p = 0.05) and gastrointestinal/digestive health issues (p = 0.03). There were statistically significant increases in the frequency of asking patients about DS use during discharge (p = 0.01), and 82% responded that the curriculum changed their DS documentation.

CONCLUSION

An online curriculum is an effective tool for presenting DS education to clinicians with the goal of improving clinicians' knowledge, confidence, and documentation practices about DS.

Polypharmacy Among Adults Aged 65 Years and Older in the United States: 1988-2010

BACKGROUND

Older adults frequently have several chronic health conditions which require multiple medications. We illustrated trends in prescription medication use over 20 years in the United States, and described characteristics of older adults using multiple medications in 2009-2010.

METHODS

Participants included 13,869 adults aged 65 years and older in the National Health & Nutrition Examination Survey (1988-2010). Prescription medication use was verified by medication containers. Potentially inappropriate medications were defined by the 2003 Beers Criteria.

RESULTS

Between 1988 and 2010 the median number of prescription medications used among adults aged 65 and older doubled from 2 to 4, and the proportion taking ≥5 medications tripled from 12.8% (95% confidence interval: 11.1, 14.8) to 39.0% (35.8, 42.3).These increases were driven, in part, by rising use of cardioprotective and antidepressant medications. Use of potentially inappropriate medications decreased from 28.2% (25.5, 31.0) to 15.1% (13.2, 17.3) between 1988 and 2010. Higher medication use was associated with higher prevalence of functional limitation, activities of daily living limitation, and confusion/memory problems in 2009-2010, although these associations did not remain after adjustment for covariates. In multivariable models, older age, number of chronic conditions, and annual health care visits were associated with increased odds of using both 1-4 and ≥5 medications. Additionally, body mass index, higher income-poverty ratio, former smoking, and non-black non-white race were associated with use of ≥5 medications.

CONCLUSIONS

Prescription medication use increased dramatically among older adults between 1988 and 2010. Contemporary older adults on multiple medications have worse health status compared with those on less medications, and appear to be a vulnerable population.

Rationale and design of a comparative effectiveness trial of home- and clinic-based self-management support coaching for older adults with asthma

Older adults with asthma face numerous barriers to effective self-management and asthma control, and experience worse outcomes than younger asthmatics. Yet, there have been no controlled trials of interventions specifically designed to improve their care and outcomes. Through a multi-stakeholder collaboration (patients, academia, community-based organizations, a state department of health, and an advocacy organization) we developed a multi-component asthma self-management support intervention to address the myriad psychosocial, functional, health status, and cognitive barriers to effective asthma self-management in adults ages 60 and older. We are recruiting 425 New Yorkers in Manhattan and the Bronx for a pragmatic randomized controlled trial with 3 arms: the intervention delivered in primary care settings or in their home, or usual care. In the intervention, care coaches use a novel screening tool to identify the specific barriers to asthma control and self-management they experience. Once identified, the coach and patient choose from a menu of actions to address it. The intervention emphasizes efficiency, flexibility, shared decision making and goal setting, communication strategies appropriate for individuals with limited cognition and literacy skills, and ongoing reinforcement and support. Additionally, we introduced asthma-specific enhancements to the electronic health records of all participating clinical practices, including an asthma severity assessment, clinical decision support, and a patient-tailored asthma action plan. Patients will be followed for 12months and interviewed at baseline, 3, 6, and 12months and data on emergency department visits and hospitalizations will be obtained through the New York State Statewide Planning and Research Cooperative System.

Medication Extraction from Electronic Clinical Notes in an Integrated Health System: A Study on Aspirin Use in Patients with Nonvalvular Atrial Fibrillation

PURPOSE

The purpose of this study was to investigate whether aspirin use can be captured from the clinical notes in a nonvalvular atrial fibrillation population.

METHODS

A total of 29,507 patients with newly diagnosed nonvalvular atrial fibrillation were identified from January 1, 2006, through December 31, 2011, and were followed up through December 31, 2012. More than 3 million clinical notes were retrieved from electronic medical records. A training data set of 2949 notes was created to develop a computer-based method to automatically extract aspirin use status and dosage information using natural language processing (NLP). A gold standard data set of 5339 notes was created using a blinded manual review. NLP results were validated against the gold standard data set. The aspirin data from the structured medication databases were also compared with the results from NLP. Positive and negative predictive values, along with sensitivity and specificity, were calculated.

FINDINGS

NLP achieved 95.5% sensitivity and 98.9% specificity when compared with the gold standard data set. The positive predictive value was 93.0%, and the negative predictive value was 99.3%. NLP identified aspirin use for 83.8% of the study population, and 70% of the low dose aspirin use was identified only by the NLP method.

IMPLICATIONS

We developed and validated an NLP method specifically designed to identify low dose aspirin use status from the clinical notes with high accuracy. This method can be a valuable tool to supplement existing structured medication data.

A cross-sectional study of provider and patient characteristics associated with outpatient disclosures of dietary supplement use

OBJECTIVE

Explore patterns in patients' disclosures of supplement use and identify provider and patient characteristics associated with disclosures.

METHODS

Cross-sectional study of 61 outpatient primary care, integrative medicine, and complementary medicine providers, and 603 of their patients. Primary outcomes were supplement disclosures (based on audio recorded office visits, post-visit patient surveys and medical record abstractions for the day of the visits).

RESULTS

Seventy-nine percent of 603 patients reported on a post-visit survey that they took a total of 2107 dietary supplements. Of those taking supplements, 232 patients (48.6%) discussed at least one supplement with their provider on the day of their office visit. However, patients disclosed only 714 (33.9%) of the 2107 supplements they were taking. Patients more frequently disclosed supplement use when they saw providers who attributed greater importance to asking about supplements. Patient characteristics such as patient activation, number of medical conditions, and use of prescription medications were not associated with disclosure of supplement use.

CONCLUSIONS

Provider rating of the importance of asking about supplements is a major factor prompting patients' disclosures of supplement use.

PRACTICE IMPLICATIONS

Provider-targeted interventions to encourage provider awareness about potential supplement-drug interactions are needed to increase disclosures about dietary supplement use.

Appropriate prescribing in the elderly: Current perspectives

Advances in medical therapeutics have undoubtedly contributed to health gains and increases in life expectancy over the last century. However, there is growing evidence to suggest that therapeutic decisions in older patients are frequently suboptimal or potentially inappropriate and often result in negative outcomes such as adverse drug events, hospitalisation and increased healthcare resource utilisation. Several factors influence the appropriateness of medication selection in older patients including age-related changes in pharmacokinetics and pharmacodynamics, high numbers of concurrent medications, functional status and burden of co-morbid illness. With ever-increasing therapeutic options, escalating proportions of older patients worldwide, and varying degrees of prescriber education in geriatric pharmacotherapy, strategies to assist physicians in choosing appropriate pharmacotherapy for older patients may be helpful. In this paper, we describe important age-related pharmacological changes as well as the principal domains of prescribing appropriateness in older people. We highlight common examples of drug-drug and drug-disease interactions in older people. We present a clinical case in which the appropriateness of prescription medications is reviewed and corrective strategies suggested. We also discuss various approaches to optimising prescribing appropriateness in this population including the use of explicit and implicit prescribing appropriateness criteria, comprehensive geriatric assessment, clinical pharmacist review, prescriber education and computerized decision support tools.

Common use of dietary supplements for bipolar disorder: a naturalistic, self-reported study

Background

Dietary supplements are taken by about half of Americans. Knowledge of dietary supplement use is important because they may interact with prescription drugs or other supplements, cause adverse reactions including psychiatric symptoms, or contain inherently toxic ingredients or contaminants. This study explores the use of dietary supplements by patients with bipolar disorder in the US.

Methods

Data were obtained from an ongoing, naturalistic study of patients with bipolar disorder who received pharmacological treatment as usual. The patients self-reported their daily mood, sleep, and medications taken, including all drugs prescribed for bipolar disorder or that the patient felt impacted their mood. These included other prescribed drugs, over-the-counter drugs and dietary supplements. Drugs that received premarketing approval from the FDA were not included as dietary supplements. Patient demographics and daily medication use were characterized.

Results

Data were available from 348 patients in the US who returned a mean 249.5 days of data. In addition to prescribed psychiatric drugs, 101 of the 348 patients (29 %) used a dietary supplement for at least 7 days and 69 (20 %) used a supplement long term (for at least 50 % of days). Of the 101 supplement users, 72 (71.3 %) took one supplement daily. The 101 patients tried over 40 different supplements, and the long-term users took 19 different supplements. The most commonly taken supplements for both groups were fish oil, B vitamins, melatonin, and multivitamins. Patients using supplements were more likely to be white (p < 0.001), older (p = 0.009), and ill for more years (p = 0.025).

Conclusions

Many patients with bipolar disorder use dietary supplements in addition to prescribed drugs. Physicians should obtain detailed information about all dietary supplements taken by patients with bipolar disorder.

Older age and steroid use are associated with increasing polypharmacy and potential medication interactions among patients with inflammatory bowel disease

BACKGROUND

Comorbidity and polypharmacy, more prevalent among older persons, may impact the treatment of patients with inflammatory bowel disease (IBD). The aims of this study were to assess the frequency of polypharmacy and medication interactions within a cohort of older patients with IBD and describe IBD treatment patterns.

METHODS

Cohort study of 190 patients with IBD 65 years or older followed at a tertiary IBD referral center from 2006 to 2012. Data collected included demographics, IBD-specific characteristics including disease activity, and comorbidity. Medication histories were extracted from medical records, and data were used to classify polypharmacy, frequency, and severity of potential medication interactions and inappropriate medication use.

RESULTS

Older patients with IBD were prescribed an average of 9 routine medications. Severe polypharmacy (≥10 routine medications) was present in 43.2% of studied patients and associated with increasing age, greater comorbidity, and steroid use. Overall, 73.7% of patients had at least 1 potential medication interaction, including 40% of patients with potential IBD medication-associated interactions. Chronic steroids were prescribed to 40% of the older patients including 24% who were in remission or with mild disease activity. Only 39.5% of patients were on immunomodulators and 21.1% on biologics. Approximately, 35% of patients were given at least 1 Beers inappropriate medication and almost 10% were receiving chronic narcotics.

CONCLUSIONS

Older patients with IBD are at increased risk for severe polypharmacy and potential major medication interactions especially with increasing comorbidity and chronic steroid use. Steroid-maintenance therapies are prevalent among the older patients with IBD with lower utilization of steroid-sparing regimens.

Potential cytochrome P-450 drug-drug interactions in adults with metastatic solid tumors and effect on eligibility for Phase I clinical trials

PURPOSE

Potential cytochrome P-450 (CYP) drug-drug interactions in adults with metastatic solid tumors and their effect on eligibility for Phase I clinical trials were characterized.

METHODS

This study included adult patients with metastatic solid tumors seen by a medical oncologist from January 2008 through July 2011. The medications used by these patients were identified. Each medication's potential for interacting with CYP isozymes was also characterized. Medication changes required to meet Phase I trial eligibility criteria were also reviewed.

RESULTS

Data from 1773 patients were analyzed: 1489 were not enrolled in a Phase I trial and 284 were enrolled in a Phase I trial. Polypharmacy was significantly more prevalent in the group enrolled in a Phase I trial compared with those not enrolled (95% versus 80%, p < 0.001). The majority of patients not enrolled in a Phase I trial were taking at least one CYP isozyme inhibitor (87%) and at least one CYP isozyme inducer (45%). In a separate analysis, four Phase I trials were evaluated. Of 295 screened patients, 3.2% could not enroll due to concurrent medications. Charts from 74 enrolled patients revealed 655 concurrent medications—93 medications required further review for eligibility involving 51 (69%) of patients. Of the 93 medications, 38 (41%) were stopped and 41 (44%) were changed for the study.

CONCLUSION

Polypharmacy and the use of medications that interact with CYP isoyzmes were common in adult patients with metastatic solid tumors. Patients enrolling in Phase I studies often require medication changes to meet eligibility requirements.

Medication Use Among Ethnically Diverse Older Adults in the United States

As primary consumers of health care and prescription medication, older adults are more susceptible to potential drug-related adverse effects and medication interactions. With growing diversity among the older adult population, understanding ethnic differences in medication use becomes increasingly important. The current study describes polypharmacy and the occurrence of underprescribing among community-dwelling, low-income individuals 55 and older from four ethnic groups: (a) African American, (b) Afro-Caribbean, (c) European American, and (d) Hispanic American. Results revealed that number of illnesses, income level, and age were three major predictors associated with polypharmacy. No underprescription was identified. Overall, prevalence of polypharmacy was 47.5%. European American individuals had the highest prevalence followed by Hispanic American, African American, and Afro-Caribbean individuals. When caring for older adults from various ethnic groups, nurses should focus their efforts on those who have multiple illnesses and sufficient income to purchase medications to reduce the risk of polypharmacy.

Comedications alter drug-induced liver injury reporting frequency: Data mining in the WHO VigiBase™

Polypharmacy is common, and may modify mechanisms of drug-induced liver injury. We examined the effect of these drug-drug interactions on liver safety reports of four drugs highly associated with hepatotoxicity. In the WHO VigiBase™, liver event reports were examined for acetaminophen, isoniazid, valproic acid, and amoxicillin/clavulanic acid. Then, we evaluated the liver event reporting frequency of these 4 drugs in the presence of co-reported medications. Each of the 4 primary drugs was reported as having more than 2000 liver events, and co-reported with more than 600 different medications. Overall, the effect of 2275 co-reported drugs (316 drug classes) on the reporting frequency was analyzed. Decreased liver event reporting frequency was associated with 245 drugs/122 drug classes, including anti-TNFα, opioids, and folic acid. Increased liver event reporting frequency was associated with 170 drugs/82 drug classes; in particular, halogenated hydrocarbons, carboxamides, and bile acid sequestrants. After adjusting for age, gender, and other co-reported drug classes, multiple co-reported drug classes were significantly associated with decreased/increased liver event reporting frequency in a drug-specific/unspecific manner. In conclusion, co-reported medications were associated with changes in the liver event reporting frequency of drugs commonly associated with hepatotoxicity, suggesting that comedications may modify drug hepatic safety.

Antiepileptics for post-herpetic neuralgia in the elderly: current and future prospects

Post-herpetic neuralgia is a painful condition and its prevalence increases with age. It is a burden for older patients and the association of age-related pharmacokinetic and pharmacodynamic changes, high co-morbidity and polypharmacy leads to the risk of adverse drug reactions and interactions. This type of neuropathic pain is particularly difficult to treat and guidelines recommend the use of gabapentinoids and some antidepressants, the utility of which may be hampered by adverse effects such as sedation, dizziness and impaired age-related renal function. Re-formulations of antiepileptics (anticonvulsants) are being developed and/or marketed and suggest interesting innovative profiles with improved bioavailability, low drug-drug interactions and better tolerability that need to be confirmed in future studies. However, there are no new antiepileptics being developed for post-herpetic neuralgia, and prospective studies specifically focused on the older population are still missing, while this age group is particularly at risk of developing shingles and chronic neuropathic pain with a deleterious impact on quality of life.

Diagnosis isn't enough: Understanding the connections between high health care utilization, chronic conditions and disabilities among U.S. working age adults

BACKGROUND

Under the ACA, new programs are being developed to enhance care coordination and reduce health care costs among people with chronic conditions, disabilities, and high utilization of health care. However, the relationships between these groups are not well understood.

OBJECTIVES

Our aims were to (1) identify high utilizers of health care in the U.S. working age (18-64) population, (2) examine the overlap between this group and people with chronic conditions and/or disabilities, (3) identify predictors of high service use or cost among these subpopulations, and (4) recommend approaches for stratification of individuals with high health care utilization.

METHODS

Using pooled national data from the Medical Expenditure Panel Survey (2006-2008), we created indices to identify elevated or high utilization and cost groups. We performed descriptive analyses, bivariate comparisons and multivariate analyses to examine the relations between these populations and individuals with chronic conditions and/or disabilities.

RESULTS

While the large majority of persons with high use/cost had chronic conditions, the minority of persons with chronic conditions had high health care utilization. However, among persons with chronic conditions, disability was a significant predictor of high utilization. Annual expenditures were significantly elevated among people with disabilities, particularly when activities of daily living were limited.

CONCLUSIONS

We conclude that medical diagnosis alone is insufficient for the development of eligibility criteria for, or the evaluation of, programs intended to better the delivery or coordination of services for high utilizers of health care services. New approaches are needed to assess functional limitations and identify ongoing needs for services and supports.

Adverse Geriatric Outcomes Secondary to Polypharmacy in a Mouse Model: The Influence of Aging

We aimed to develop a mouse model of polypharmacy, primarily to establish whether short-term exposure to polypharmacy causes adverse geriatric outcomes. We also investigated whether old age increased susceptibility to any adverse geriatric outcomes of polypharmacy. Young (n= 10) and old (n= 21) male C57BL/6 mice were administered control diet or polypharmacy diet containing therapeutic doses of five commonly used medicines (simvastatin, metoprolol, omeprazole, acetaminophen, and citalopram). Mice were assessed before and after the 2- to 4-week intervention. Over the intervention period, we observed no mortality and no change in food intake, body weight, or serum biochemistry in any age or treatment group. In old mice, polypharmacy caused significant declines in locomotor activity (pre minus postintervention values in control 2 ± 13 counts, polypharmacy 32 ± 7 counts,p< .05) and front paw wire holding impulse (control -2.45 ± 1.02 N s, polypharmacy +1.99 ± 1.19 N s,p< .05), loss of improvement in rotarod latency (control -59 ± 11 s, polypharmacy -1.7 ± 17 s,p< .05), and lowered blood pressure (control -0.2 ± 3 mmHg, polypharmacy 11 ± 4 mmHg,p< .05). In young mice, changes in outcomes over the intervention period did not differ between control and polypharmacy groups. This novel model of polypharmacy is feasible. Even short-term polypharmacy impairs mobility, balance, and strength in old male mice.

Drug management in the elderly adult with chronic kidney disease: a review for the primary care physician

With advancing age, the functional reserve of many organs tends to decrease. In particular, the lean body mass, the levels of serum albumin, the blood flow to the liver, and the glomerular filtration rate are reduced in elderly individuals and can be further impaired by the concomitant presence of acute or chronic kidney disease. Moreover, patients with kidney disease are often affected by comorbid processes and are prescribed multiple medications. The aging process also modifies some drug interactions, including the affinity of some drugs for their receptor, the number of receptors, and the cell responses upon receptor activation. Therefore, older patients with kidney disease are particularly susceptible to the risks of adverse drug reactions. Planning a pharmacological regimen in such patients is confounded by the paucity of information available on the pharmacokinetic and pharmacodynamic profiles of a large number of drugs commonly used in this group of patients. Finally, many aged patients suffer from unintentional poor compliance. In this review, the problems physicians face in designing safe and effective medication management in elderly individuals are discussed, paying attention to those more frequently used, which may be potentially harmful in patients with kidney disease. The risks of overdosing and underdosing are outlined, and some recommendations to reduce the risk of adverse drug reactions are provided. A review of the literature covering the field of drug management in older patients with kidney disease was performed by selecting those articles published between January 1, 1990, and December 1, 2014, using PubMed as a search engine with the keywords elderly, kidney disease, drugs, drug interaction, and renal function.

Medication and Dietary Supplement Interactions among a Low-Income, Hospitalized Patient Population Who Take Cardiac Medications

Purpose. To identify characteristics associated with the use of potentially harmful combinations of dietary supplements (DS) and cardiac prescription medications in an urban, underserved, inpatient population. Methods. Cardiac prescription medication users were identified to assess the prevalence and risk factors of potentially harmful dietary supplement-prescription medication interactions (PHDS-PMI). We examined sociodemographic and clinical characteristics for crude (χ (2) or t-tests) and adjusted multivariable logistic regression associations with the outcome. Results. Among 558 patients, there were 121 who also used a DS. Of the 110 participants having a PHDS-PMI, 25% were asked about their DS use at admission, 75% had documentation of DS in their chart, and 21% reported the intention to continue DS use after discharge. A multivariable logistic regression model noted that for every additional medication or DS taken the odds of having a PHDS-PMI increase and that those with a high school education are significantly less likely to have a PHDS-PMI than those with a college education. Conclusion. Inpatients at an urban safety net hospital taking a combination of cardiac prescription medications and DS are at a high risk of harmful supplement-drug interactions. Providers must ask about DS use and should consider the potential for interactions when having patient discussions about cardiac medications and DS.

Medical reconciliation of dietary supplements: don't ask, don't tell

OBJECTIVE

To explore inpatient reconciliation of dietary supplement (DS) use and determine characteristics associated with DS documentation.

METHODS

We analyzed DS use among 558 inpatients recruited from the Re-Engineered Discharge clinical trial to identify: (1) if patients self-reported DS and (2) if DS use was documented at admission. We examined socio-demographics for association with documentation using chi squares and t-tests. Logistic regression was performed to assess adjusted associations with DS documentation.

RESULTS

Sixty percent reported DS use (n=333). Among users, 36% had admission DS documentation, 20% were asked about use at admission, 18% reported disclosing use to a provider, and 48% reported they would continue to use DS. Overall, 6% of participants were asked, disclosed, and had documentation of DS. Logistic regression revealed increased age associated with lower odds of DS documentation. Identifying as Hispanic or African American reduces DS documentation odds compared to those identifying as white.

CONCLUSIONS

There is lack of consistent DS medical reconciliation in the inpatient setting. While more than half of patients used DS prior to hospitalization, most were not asked about use on admission.

PRACTICE IMPLICATIONS

This study adds to literature on medical reconciliation which requires that providers inquire and document patient DS use.

Detection and characterization of SiO2 and TiO2 nanostructures in dietary supplements

Nanomaterials are beginning to enter our daily lives through various consumer products as the result of technology commercialization. The development of methodologies to detect the presence of nanomaterials in consumer products is an essential element in understanding our exposure. In this study, we have developed methods for the separation and characterization of silicon dioxide (SiO2) and titanium dioxide (TiO2) nanostructures in dietary supplements marketed in products specifically targeted for women. A total of 12 commercial products claiming the inclusion of SiO2 and TiO2, but not making any claims regarding the particle size, were randomly selected for purchase through various retailers. To isolate nanostructures from these products, a simple methodology that combines acid digestion and centrifugation was utilized. Once isolated, the chemical composition, size, morphology, and crystal structure were characterized using mass spectroscopy, light scattering, electron microscopy, and X-ray diffraction techniques. SiO2 and TiO2 nanostructures were detected in 11 of 12 products using these methods. Many of the isolated nanoscale materials showed a high degree of aggregation; however, identified individual structures had at least one dimension below 100 nm. These robust methods can be used for routine monitoring of commercial products for nanoscale oxides of silica and titanium.

Older adults' use of care strategies in response to general and upper respiratory symptoms

This study examined the use of complementary and medical treatments, both individually and in combination, to address common general and upper respiratory symptoms. Data for the analysis were collected from a series of 18 daily diary questionnaires administered to community-living older African American and white adults living in rural counties in North Carolina. Participants reported symptoms experienced on each diary day and the treatment strategies they used each day in response to the particular symptom(s). Older adults used diverse categories of strategies to treat symptoms; treatment strategies were used inconsistently across symptoms. Use of only complementary strategies, only medical conventional strategies, or both complementary and medical strategies to treat any one symptom rarely corresponded to the use of the same strategy to address other symptoms. Future research would benefit from analyzing how older adults use health care strategies across symptom categories.

Racial differences in anticholinergic use among community-dwelling elders

OBJECTIVE

Few studies have examined racial differences in potentially inappropriate medication use. The objective of this study was to examine racial disparities in using prescription and/or nonprescription anticholinergics, a type of potentially inappropriate medication, over time.

DESIGN

Longitudinal.

SETTING

Data from the Health, Aging, and Body Composition Study (years 1, 5, and 10).

PARTICIPANTS

Three thousand fifty-five community-dwelling older adults, both blacks and whites, at year 1.

MAIN OUTCOME MEASURE

Highly anticholinergic medication use per the 2012 American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

RESULTS

Blacks represented 41.4% of the participants at year 1. At year 1, 13.4% of blacks used an anticholinergic medication compared with 17.8% of whites, and this difference persisted over the ensuing 10-year period. Diphenhydramine was the most common anticholinergic medication reported at baseline and year 5, and meclizine at year 10, for both races. Controlling for demographics, health status, and access to care factors, blacks were 24% to 45% less likely to use any anticholinergics compared with whites over the years considered (all P < 0.05).

CONCLUSION

The use of prescription and/or nonprescription anticholinergic medications was less common in older blacks than whites over a 10-year period, and the difference was unexplained by demographics, health status, and access to care.

A Brief Educational Intervention Improves Medication Safety Knowledge in Grandparents of Young Children

BACKGROUND AND OBJECTIVES

Increasing grandparent-grandchild interactions have not been targeted as a potential contributing factor to the recent surge in pediatric poisonings. We hypothesized that in grandparents with a young grandchild, a single educational intervention based on the PROTECT "Up & Away" campaign will improve safe medication knowledge and storage at follow-up from baseline.

METHODS

This prospective cohort study validated the educational intervention and survey via cognitive debriefing followed by evaluation of the educational intervention in increasing safe medication storage. Participants had to read and speak English and have annual contact with one grandchild ≤ 5-years-old. Participants were recruited from a convenience sample of employees in a regional healthcare system. They completed a pre-intervention survey querying baseline demographics, poisoning prevention knowledge, and medication storage, followed by the educational intervention and post-intervention survey. Participants completed a delayed post-intervention survey 50-90 days later assessing medication storage and poisoning prevention knowledge. Storage sites were classified as safe or unsafe a priori; a panel classified handwritten responses.

RESULTS

120 participants were enrolled; 95 (79%) completed the delayed post-intervention survey. Participants were predominantly female (93%) and white (76%); 50% had a clinical degree. Participants averaged 1.9 grandchildren. Initially, 23% of participants reported safe medication storage; this improved to 48% after the intervention (OR 6.4; 95% CI = 2.5-21.0). 78% of participants made at least one improvement in their medication storage after the intervention even if they did not meet all criteria for safe storage. Participants also demonstrated retention of poisoning prevention knowledge.

CONCLUSIONS

This brief educational intervention improved safe medication storage and poisoning prevention knowledge in grandparents of young children; further evaluation of this intervention is warranted.

Appropriate prescribing and important drug interactions in older adults

Polypharmacy, specifically the overuse and misuse of medications, is associated with adverse health events, increased disability, hospitalizations, and mortality. Mechanisms through which polypharmacy may increase adverse health outcomes include decreased adherence, increased drug side effects, higher use of potentially inappropriate medications, and more frequent drug-drug interactions. This article reviews clinical problems associated with polypharmacy and presents a framework to optimize prescribing for older adults.

Randomized trial of glucosamine and chondroitin supplementation on inflammation and oxidative stress biomarkers and plasma proteomics profiles in healthy humans

BACKGROUND

Glucosamine and chondroitin are popular non-vitamin dietary supplements used for osteoarthritis. Long-term use is associated with lower incidence of colorectal and lung cancers and with lower mortality; however, the mechanism underlying these observations is unknown. In vitro and animal studies show that glucosamine and chondroitin inhibit NF-kB, a central mediator of inflammation, but no definitive trials have been done in healthy humans.

METHODS

We conducted a randomized, double-blind, placebo-controlled, cross-over study to assess the effects of glucosamine hydrochloride (1500 mg/d) plus chondroitin sulfate (1200 mg/d) for 28 days compared to placebo in 18 (9 men, 9 women) healthy, overweight (body mass index 25.0-32.5 kg/m2) adults, aged 20-55 y. We examined 4 serum inflammatory biomarkers: C-reactive protein (CRP), interleukin 6, and soluble tumor necrosis factor receptors I and II; a urinary inflammation biomarker: prostaglandin E2-metabolite; and a urinary oxidative stress biomarker: F2-isoprostane. Plasma proteomics on an antibody array was performed to explore other pathways modulated by glucosamine and chondroitin.

RESULTS

Serum CRP concentrations were 23% lower after glucosamine and chondroitin compared to placebo (P = 0.048). There were no significant differences in other biomarkers. In the proteomics analyses, several pathways were significantly different between the interventions after Bonferroni correction, the most significant being a reduction in the "cytokine activity" pathway (P = 2.6 x 10-16), after glucosamine and chondroitin compared to placebo.

CONCLUSION

Glucosamine and chondroitin supplementation may lower systemic inflammation and alter other pathways in healthy, overweight individuals. This study adds evidence for potential mechanisms supporting epidemiologic findings that glucosamine and chondroitin are associated with reduced risk of lung and colorectal cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01682694.

Geographic region and racial variations in polypharmacy in the United States

PURPOSE

Medications can have unintended effects. High medication use populations may benefit from increased regimen oversight. Limited knowledge exists concerning racial and regional polypharmacy variation. We estimated total medication distributions (excluding supplements) of American black and white adults and assessed racial and regional polypharmacy variation.

METHODS

REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort data (n = 30,239 U.S. blacks and whites aged ≥45 years) were analyzed. Home pill bottle inspections assessed the last two weeks' medications. Polypharmacy (≥8 medications) was determined by summing prescription and/or over-the-counter ingredients. Population-weighted logistic regression assessed polypharmacy's association with census region, race, and sex.

RESULTS

The mean ingredient number was 4.12 (standard error = 0.039), with 15.7% of REGARDS using 8 ingredients or more. In crude comparisons, women used more medications than men, and blacks and whites reported similar mean ingredients. A cross-sectional, logistic model adjusting for demographics, socioeconomics, and comorbidities showed increased polypharmacy prevalence in whites versus blacks (OR [95% CI]: 0.63, [0.55-0.72]), women (1.94 [1.68-2.23]), and Southerners (broadly Southeasterners and Texans; 1.48 [1.17-1.87]) versus Northeasterners (broadly New England and upper Mid-Atlantic). Possible limitations include polypharmacy misclassification and model misspecification.

CONCLUSION

Polypharmacy is common. Race and geography are associated with polypharmacy variation. Further study of underlying factors explaining these differences is warranted.

Concurrent use of drugs and supplements in a community-dwelling population aged 50 years or more: potential benefits and risks

BACKGROUND

The use of vitamin and mineral (VMs) and non-vitamin/non-mineral supplements (non-VMs) in the general population and the older population in developed countries has increased. When combined with drugs, their use can be associated with benefit and potential risks.

OBJECTIVE

The aims of this study were to determine the extent and associated factors of the combined use of drugs and VM/non-VM supplements, and to examine the potential major drug-supplement interactions

METHODS

Cross-sectional analysis of first-wave data of TILDA, The Irish Longitudinal Study on Ageing, nationally representative a cohort including 8,081 community-dwelling persons aged ≥50 years. Prevalences including 95 % confidence intervals (CI) were weighted to the population. Group differences in drug and supplement use were assessed using Pearson's Chi-square test, and associations between concurrent drug-supplement use and covariates were assessed using logistic regression. Potential interactions between drugs and supplements were assessed using relevant sources.

RESULTS

Every seventh respondent (14.0 %; 95 % CI 13.1-15.0) reported regular concurrent use of drugs and supplements; 7.9 % (95 % CI 7.3-8.6) took only VMs, 3.9 % (95 % CI 3.4-4.4) took only non-VMs, and 2.2 % (95 % CI 1.8-2.6) took at least one of each concurrently with drugs. Concurrent use was more prevalent in women and in the oldest (≥75 years) group. Chronic disease, female sex, third-level education and private medical insurance were associated with an increased likelihood of use of both supplement types, whereas those classed as employed were much less likely to use any supplements. Supplements were combined with drugs in all of the commonly prescribed therapeutic groups, ranging from just under 60 % with drugs for bone diseases to 15.7 % with drugs for diabetes. Potential major drug-supplement interactions were detected in 4.5 % (95 % CI 3.4-5.8) of concurrent drug-supplement users, and were more prevalent in older respondents.

CONCLUSIONS

Concurrent use of drugs and supplements among those aged over 50 years in the Irish population is substantial and increases with age. There is considerable variation in usage, and the outcome of this approach is evidence of unmet need and therefore unrealised benefits among some subgroups, and of exposure to avoidable and potential serious drug interactions among others.

Assessing a conceptual model of over-the-counter medication misuse, adverse drug events and health-related quality of life in an elderly population

AIM

The objectives of the present study were to test Spilker's quality of life model in the elderly population consuming over-the-counter (OTC) medications. It was hypothesized that OTC medication misuse increases adverse drug events (ADEs), ADEs as a result of OTC medication misuse decrease health-related quality of life (HRQoL) and the impact of OTC medication misuse on patients' HRQoL is fully medicated by ADEs associated with OTC medications.

METHODS

Data were used from a previously carried out cross-sectional study using survey instruments with elderly patients consuming OTC medications in Houston, Texas, USA. The presence/absence of OTC misuse was assessed by an expert panel based on patient reported information on drug use characteristics; ADE was self-reported and HRQoL was measured using the Short Form-12v2, which contains a physical component summary score (PCS) and a mental component summary score (MCS).

RESULTS

Of the 154 respondents, 18.2% misused OTC medications and 22.1% reported ADE as a result of OTC medications. The mean ± SD score of PCS and MCS was 40.6 ± 6.8 and 46.4 ± 7, respectively. The hypothesized framework provided a well-fitted solution to the data (χ(2)  = 1.387, d.f. = 2, P = 0.49; weighted root mean square residual = 0.317). Misuse of OTC medications significantly increased ADEs associated with OTC medications (β = 0.298) and increased ADEs significantly decreased patient reported PCS (β = -0.312), but not MCS (β = -0.213). OTC medication misuse indirectly decreased PCS and MCS by mediating the effect of an increase in ADE; however, the association was not statistically significant.

CONCLUSIONS

Misuse of OTC medications is highly associated with ADEs. ADEs are capable of decreasing the physical health of elderly patients.

Association between Total Daily Doses with duration of hospitalization among readmitted patients in a multi-ethnic Asian population

Increased length of stay (LOS) in the hospital incurs substantial financial costs on the healthcare system. Multiple factors are associated with LOS. However, few studies have been done to associate the impact of Total Daily Doses (TDD) and LOS. Hence, the aim of this study is to examine the association between patients’ LOS upon readmission and their TDD before readmission. A retrospective cross-sectional study of readmission cases occurring from 1st January to 31st March 2013 was conducted at a regional hospital. Demographics and clinical variables were collected using electronic medical databases. Univariable and multiple linear regressions were used. Confounders such as comorbidities and drug related problems (DRP) were controlled for in this study. There were 432 patients and 649 readmissions examined. The average TDD and LOS were 18.04 ± 8.16 and 7.63 days ± 7.08 respectively. In the univariable analysis, variables that were significantly associated with the LOS included age above 75 year-old, race, comorbidity, number of comorbidities, number of medications, TDD and thrombocytopenia as DRPs. In the multiple linear regression, there was a statistically significant association between TDD (β = 0.0733, p = 0.030) and LOS. Variables that were found significant were age above 75 year-old (β = 1.5477, p = 0.008), Malay (β = −1.5123, p = 0.033), other races (β = −2.6174, p = 0.007), depression (β = 2.1551, p = 0.031) and thrombocytopenia as a type of DRP (β = 7.5548, p = 0.027). When TDD was replaced with number of medications, number of medications (β = 0.1487, p = 0.021), age of 75 year-old (β = 1.5303, p = 0.009), Malay (β = −1.4687, p = 0.038), race of others (β = −2.6499, p = 0.007), depression (β = 2.1951, p = 0.028) and thrombocytopenia as a type of DRP (β = 7.5260, p = 0.028) were significant. In conclusion, a significant relationship between TDD and number of medications before readmission and the LOS upon readmission was established. This finding highlights the importance of optimizing patients’ TDD in the attempt of reducing their LOS.

Polypharmacy in heart failure patients

In heart failure (HF), the progressive use of multiple drugs and a complex therapeutic regimen is common and is recommended by international guidelines. With HF being a common disease in the elderly, patients often have numerous comorbidities that require additional specific treatment, thus producing a heavy pill burden. Polypharmacy, defined as the chronic use of five or more medications, is an underestimated problem in the management of HF patients. However, polypharmacy has an important impact on HF treatment, as it often leads to inappropriate drug prescription, poor adherence to pharmacological therapies, drug-drug interactions, and adverse effects. The growing complexity of HF patients, whose mean age increases progressively and who present multiple comorbidities, suggests the need for newer models of primary care to improve the management of HF patients. Self-care, telemonitoring, and natriuretic peptide-guided therapy represent promising new HF care models to face the complexity of the disease and its therapeutic regimen.