Herbal, Prescribed, and Over-the-Counter Drug Use in Older Women: Prevalence of Drug Interactions

Drug-Drug Interactions With Over-The-Counter Medicines: Mind the Unprescribed

BACKGROUND

This review provides a summary of the currently available clinical data on drug-drug interactions (DDIs) involving over-the-counter (OTC) medicines. It aims to educate and increase awareness among health care providers and to support decisions in daily practice.

METHODS

An extensive literature search was performed using bibliographic databases available through PubMed.gov. An initial structured search was performed using the keywords "drug-drug-interaction AND (over-the-counter OR OTC)," without further restrictions except for the language. The initial results were screened for all described DDIs involving OTC drugs, and further information was gathered specifically on these drugs using dedicated database searches and references found in the bibliography from the initial hits.

RESULTS

From more than 1200 initial hits (1972-June 2021), 408 relevant publications were screened for DDIs involving OTC drugs, leading to 2 major findings: first, certain types of drug regimens are more prone to DDIs or have more serious DDI-related consequences, such as antiretroviral, anti-infective, and oral anticancer therapies. Second, although most DDIs involve OTC drugs as the perpetrators, some prescription drugs (statins or phosphodiesterase-5 inhibitors) that currently have OTC status can be identified as the victims in DDIs. The following groups were identified to be frequently involved in DDIs: nonsteroidal anti-inflammatory drugs, food supplements, antacids, proton-pump inhibitors, H2 antihistamines, laxatives, antidiarrheal drugs, and herbal drugs.

CONCLUSIONS

The most significant finding was the lack of high-quality evidence for commonly acknowledged interactions. High-quality interaction studies involving different phenotypes in drug metabolism (cytochrome P450) and distribution (transporters) are urgently needed. This should include modern and critical drugs, such as oral anticancer medications and direct oral anticoagulants.

Use and costs of non-prescription medications among people with spinal cord injury

OBJECTIVES

The study objectives were to assess the prevalence of, and factors associated with the use and costs of non-prescription medications among people with spinal cord injury.

DESIGN

Observational design; a cross-sectional online survey Setting: Community in Canada Participants: Individuals with spinal cord injury Interventions: Not applicable Main Outcome Measures: Not applicable Results: A total of 160 individuals participated in this study. Of all study participants, 83% reported that they used at least one non-prescription medication over the last 12 months. On an average, participants spent $52 per month on non-prescription medications. The average use and monthly expenditure did not differ significantly by age, sex, or injury parameters. Vitamins and minerals were most commonly used and constituted 62% of all non-prescription medications listed by the participants. Musculoskeletal issues were the most common health problems for which non-prescription medications were used.

CONCLUSION

Non-prescription medications are a common part of therapeutic drug regimens for people with spinal cord injuries and are purchased as an out-of-pocket expense. These products may or may not have established benefits. Knowledge about the use of non-prescription medications may help prescribers to improve drug safety, medication affordability, and quality of pharmacotherapy for their patients with spinal cord injury.

Prevalence of drug-herb and drug-supplement interactions in older adults: a cross-sectional survey

Background

Polypharmacy is common among older adults, with increasing numbers also using prescription drugs with herbal medicinal products (HMPs) and dietary supplements. There is no reliable evidence from the UK on concurrent use of HMPs and dietary supplements with prescription drugs in older adults.

Aim

To establish prevalence of concurrent prescription drugs, HMPs, and dietary supplements among UK community-dwelling older adults and identify potential interactions.

Design and setting

Cross-sectional survey of older adults registered at two general practices in South East England.

Method

A questionnaire asking about prescription medications, HMPs, and sociodemographic information was posted to 400 older adults aged ≥65 years, identified as taking ≥1 prescription drug.

Results

In total 155 questionnaires were returned (response rate = 38.8%) and the prevalence of concurrent HMPs and dietary supplements with prescriptions was 33.6%. Females were more likely than males to be concurrent users (43.4% versus 22.5%; P = 0.009). The number of HMPs and dietary supplements ranged from 1 to 8, (mean = 3, median = 1; standard deviation = 1.65). The majority of concurrent users (78.0%) used dietary supplements with prescription drugs. The most commonly used dietary supplements were cod liver oil, glucosamine, multivitamins, and vitamin D. Others (20.0%) used only HMPs with prescription drugs. Common HMPs were evening primrose oil, valerian, and Nytol Herbal^® (a combination of hops, gentian, and passion flower). Sixteen participants (32.6%) were at risk of potential adverse drug interactions.

Conclusion

GPs should routinely ask questions regarding herbal and supplement use, to identify and manage older adults at potential risk of adverse drug interactions.

Preferences and attitudes of older adults of Bialystok, Poland toward the use of over-the-counter drugs

Purpose

The aim of the study was to assess preferences and attitudes toward the use of over-the-counter (OTC) drugs among residents of Bialystok aged 60 or older.

Patients and methods

The study included 170 people, inhabitants of Bialystok aged over 60: 85 students of the University of a Healthy Senior and the University of Psychogeriatric Prophylaxis, and 85 students of the University of the Third Age in Bialystok. The study made use of a diagnostic survey conducted via a questionnaire prepared by the authors.

Results

The vast majority of respondents bought OTC drugs for own use. About one-third of the respondents from each analyzed group bought OTC drugs less often than once every 3 months. Over half of the respondents bought OTC drugs due to a cold. A majority of the respondents were of the opinion that OTC drugs should be sold only in pharmacies. Over 40% of seniors took 1 OTC drug regularly. Most respondents also took vitamins and supplements. The main sources of information on OTC drugs for the studied seniors were their doctor and pharmacist. Respondents did not always consult the treatment method with a doctor or pharmacist. Over half of the respondents familiarized themselves with the contents of the OTC drug package leaflet. Over three-quarters of the respondents were familiar with drug disposal methods; however, despite declarations of being familiar with these principles, a significant percentage did not bring back medication to a pharmacy or clinic, or threw the drugs into the trash.

Conclusion

Our study found that in our sample there were many OTC drug consumers who did not always demonstrate responsible attitudes toward using this group of drugs. Thus, older people should be educated on the possible adverse effects of taking OTC drugs without consulting a doctor or pharmacist as well as basic drug disposal principles. Furthermore, legislation should be introduced that will limit the wide availability of OTC drugs, particularly to the elderly; and thus, lower the costs of hospitalization and outpatient treatment of this age group. Also, a wider-reaching study should be conducted. It should include a larger group of elderly people as well as information on intake of prescribed medications in order to be able to determine the frequency of drug consumption in this population, as well as seniors' preferences and attitudes in this regard.

Concurrent Use of Prescription Drugs and Herbal Medicinal Products in Older Adults: A Systematic Review

Background

The use of herbal medicinal products (HMPs) is common among older adults; however, little is known about concurrent use with prescription drugs, as well as potential interactions associated with such combinations.

Objective

The aim of this systematic review was to identify and evaluate the literature on concurrent prescription and HMP use among older adults to assess prevalence, patterns, potential interactions and factors associated with this use.

Methods

Systematic searches were conducted in the MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, Web of Science and Cochrane databases from inception to May 2017 for studies reporting concurrent use of prescription medicines with HMPs in adults ≥ 65 years of age. Quality was assessed using the Joanna Briggs Institute checklists. And the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) three-stage approach to mixed method research was used to synthesise data.

Results

Twenty-two studies were included. A definition of HMPs or what was considered an HMP was frequently missing. Prevalence of concurrent use by older adults varied widely between 5.3 and 88.3%. Prescription medicines most combined with HMPs were antihypertensive drugs, β-blockers, diuretics, antihyperlipidemic agents, anticoagulants, analgesics, antihistamines, antidiabetics, antidepressants and statins. The HMPs most frequently used were Ginkgo biloba, garlic, ginseng, St John’s wort, Echinacea, saw palmetto, evening primrose oil and ginger. Potential risks of bleeding due to the use of Ginkgo biloba, garlic or ginseng with aspirin or warfarin was the most reported herb–drug interaction. Some data suggest being female, and having a lower household income and less than a high-school education were associated with concurrent use.

Conclusion

The prevalence of concurrent prescription drugs and HMP use among older adults is substantial and potential interactions have been reported. Knowledge of the extent and manner in which older adults combine prescription drugs will aid healthcare professionals in appropriately identifying and managing patients at risk. Systematic Review Registration Number: PROSPERO 2014:CRD42014009091.

Electronic supplementary material

The online version of this article (10.1007/s40266-017-0501-7) contains supplementary material, which is available to authorized users.

Pain Management in Older Adults

Treating pain in older adults can be complex because of the age-related physiologic changes, comorbidities, and polypharmacy. Thus, an individualized, multimodal treatment approach is recommended. Treatment plans should include pharmacologic and nonpharmacologic strategies. Several important clinical guidelines and expert panel statements are available to guide health care providers in the best practices for treating pain in older adults. This article provides evidence-based recommendations for pharmacological and non-pharmacological pain management in older adults.

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.

Correlation between the use of ‘over-the-counter’ medicines and adherence in elderly patients on multiple medications

BACKGROUND

Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC)medicines. The use of OTC medicine has been reported as common amongst elderly patients.

OBJECTIVE

To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients.

SETTING

Non-institutionalised elderly patients in Denmark.

METHODS

Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the me an adherence rate for all drugs consumed was\80 %. Different sensitivity analyses were made where adherence was defined different.

MAIN OUTCOME MEASURE

Medication adherence based on pill-count.

RESULTS

A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 %confidence interval 0.18–0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore,separate analyses of herbal medicines, dietary supplements,or non-prescribed drugs did not correlate with adherence to prescriptions.

CONCLUSION

Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately.

Correlation between the use of 'over-the-counter' medicines and adherence in elderly patients on multiple medications

Background Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC) medicines. The use of OTC medicine has been reported as common amongst elderly patients. Objective To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients. Setting Non-institutionalised elderly patients in Denmark. Methods Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the mean adherence rate for all drugs consumed was <80 %. Different sensitivity analyses were made where adherence was defined different. Main outcome measure Medication adherence based on pill-count. Results A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 % confidence interval 0.18-0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore, separate analyses of herbal medicines, dietary supplements, or non-prescribed drugs did not correlate with adherence to prescriptions. Conclusion Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately.

Treatment of invasive candidiasis in the elderly: a review

Fungi are major causes of infections among immunocompromised or hospitalized patients with serious underlying diseases and comorbidities. Candida species remain the most important cause of opportunistic infections worldwide, affecting predominantly patients over 65 years old, while they are considered to be the fourth most common cause of nosocomial bloodstream infections. The rapidly growing elderly population has specific physiological characteristics, which makes it susceptible to colonization and subsequent infection due to Candida species. Comorbidities and multidrug use should be taken into account any time the therapeutic regimen is under consideration. Different classes of antifungal drugs are available for the treatment of invasive fungal infections but echinocandins, apart from their activity against resistant strains (Candida glabrata and Candida krusei), seem to be safe, with limited adverse events and minimal drug-drug interactions in comparison to the other regimens. Therefore, these agents are strongly recommended when dealing with elderly patients suffering from an invasive form of Candida infection.

Drug-induced liver injury in the elderly

Historically, the elderly have been considered to be at increased risk for drug-induced liver injury (DILI). Animal studies have demonstrated changes in hepatic physiology that affect drug metabolism in the aging liver; however, there is no evidence that this leads to any appreciable deterioration of liver function in healthy older humans. Updated data from international DILI registries give us pause to consider whether the elderly are truly at increased risk to develop hepatic injury. Instead, hepatotoxicity in the elderly appears to be more a function of drug exposure, polypharmacy and drug-drug interactions. Isoniazid and benoxaprofen are the only two agents with a well-studied correlation between increasing age and risk of DILI. Nevertheless, given the increasing proportion of patients over age 65 in the U.S. and abroad, the influence of age on the risk of DILI is the focus of this review.

Absence of 'over-the-counter' medicinal products in on-line prescription records: a risk factor of overlooking interactions in the elderly

PURPOSE

To assess possible origins of harmful interactions in elderly patients arising from the current absence of information on over-the-counter (OTC) medicines in the Danish 'on-line prescription record'.

METHODS

Information on current use of prescription drugs and OTC medicinal products (non-prescription drugs, herbal medicine, dietary supplements, and others) was collected by home visit interviews. The latter OTC products were not listed in an on-line prescription record that covered the previous two years. Information on interactions between OTC medicines and between OTC products and prescription drugs was obtained from the Danish National Drug Interaction Database.

RESULTS

Of the 309 patients recruited (median age 75 years, interquartile range (IQR) 70-81), 229 (74%) used 568 OTC medicines not listed in the Danish 'on-line prescription record', amongst which we identified 166 potential interactions - between OTC treatments or between OTC and prescription drugs. Fifty percent of patients taking OTC medicines were exposed to potential interactions, i.e. one to three instances per patient. Twenty-five percent of patients exposed to interactions experienced interaction listed as 'Can be used with certain precautions'.

CONCLUSION

The absence of information on OTC products in an on-line prescription record entails a risk of overlooking interactions in elderly patients. Such products should be included in on-line medication records to prevent adverse effects from interactions. However, online medication records are not available in all countries and as inclusion of data on OTC drugs seem not to be feasible presently. Still, it is highly recommended that the patient's drug list is reviewed on a regular basis.

Isothiocyanate-drug interactions in the human adenocarcinoma cell line Caco-2

Isothiocyanates, among which alyssin is counted, are the compounds that have proved chemopreventive properties and the ability to induce the 2 and the 3 detoxification phase by affecting the transcription factor nuclear erythroid 2-related factor (Nrf2). Having a positive effect on the human body, these compounds are used as dietary supplements. Because of the observed increase in the consumption of dietary supplements taken along with the drugs routinely used in medical practice, this study examined the possibility of interactions between alyssin and drugs, which could have an impact on cell metabolism. We have determined the effects of the tested substances and their interactions on the expression and activity of the phase 2 genes, as well as on the drug transport, which could be influenced by affecting the expression of transport proteins that belong to the 3 phase of metabolism. It was also studied whether the transcription factor Nrf2 is responsible for the interactions that occurred. The results showed that the interactions between alyssin and the tested drugs strengthen or weaken the effect of the drugs given separately depending on the concentration of alyssin and the type of drug. Even though Nrf2 is involved in the interaction, it seems that it is not the only factor regulating the interactions between the tested medications.

Pain Management in the Elderly: An FDA Safe Use Initiative Expert Panel's View on Preventable Harm Associated with NSAID Therapy

Optimization of current pain management strategies is necessary in order to reduce medication risks. Promoting patient and healthcare provider education on pain and pain medications is an essential step in reducing inadequate prescribing behaviors and adverse events. In an effort to raise awareness on medication safety, the FDA has launched the Safe Use Initiative program. The program seeks to identify areas with the greatest amount of preventable harm and help promote new methods and practices to reduce medication risks. Since the establishment of the program, FDA's Safe Use initiative staff convened a panel of key opinion leaders throughout the medical community to address pain management in older adults (≥65 years of age). The aim of the expert panel was to focus on areas where significant risk occurs and where potential interventions will be feasible, implementable, and lead to substantial impact. The panel suggested one focus could be the use of NSAIDs for pain management in the elderly.

Self-medication with nutritional supplements and herbal over-thecounter products

In recent years, the popularity increased for nutritional supplements and herbal products. Prescription drugs, but not herbal therapies are paid by health insurances. They are sold over-the-counter (OTC) on the patients’ own expense. However, there are potential risks of self-medication, e.g. incorrect self-diagnosis, severe adverse reactions, dangerous drug interactions, risk of addiction etc. They are often used by patients at their own discretion without knowledge of and control by their physicians. Certain users are at risk of intoxication. Multiple medications taken by older patients increase the risk for adverse drug reactions, drug-drug interactions, and compliance problems for this age group (polypharmacy). Herbals should be discontinued prior to operations to avoid interactions with anesthetics or anticoagulants. Herbal preparations may also be carcinogenic or interfere with cancer treatments. Pregnant women use various OTC preparations. However, in many cases, it is unclear whether their use is safe for mother or baby. Self-medication with herbals is also largely distributed among anxious and depressive patients, and patients with other conditions and symptoms. The popularity of herbal products has also brought concerns on quality, efficacy and safety. Cases of botanical misidentification, contaminations with heavy metals, pesticides, radioactivity, organic solvents, microbials as well as adulteration with chemical drugs necessitate the establishment of international quality control standards. Hepatotoxic effects have been reported for more than 300 plant species, and some commonly used herbs have been demonstrated to interact with Western medication. Health care professionals have a critical responsibility assessing the self-care ability of their patients. Databases are available for pharmacists with information on action, side effects and toxicities as well as herb-drug interactions. There is a need for established guidelines regarding the correct use of nutritional supplements and herbal OTC preparations (phytovigilance). Physicians, pharmacists, and other health care professionals have to counsel patients and the general public on the benefits and risks associated with herbal drugs. Information centers for consumers and general practitioners are needed, and convincing evidence on safety and efficacy of herbal products has to be demonstrated in placebo-controlled, double blind and randomized clinical trials.

Hypertension Secondary to Ingestion of Licorice Root Tea

Objective:

To report a case of hypertension secondary to ingestion of licorice root tea.

Case Summary:

A 46-year-old African American female with newly diagnosed stage 1 hypertension presented with a blood pressure measurement of 144/81 mm Hg and a reduced plasma potassium level of 3.2 mEq/L. The patient attempted lifestyle modifications prior to initiating an antihypertensive agent, but at a follow-up appointment, her blood pressure remained elevated. A current laboratory panel revealed a depressed morning plasma aldosterone concentration (PAC) of 5 ng/dL and low morning plasma renin activity (PRA) of 0.13 ng/mL/h. Later it was revealed that the patient regularly (1–2 cups/day) consumed “Yogi Calming” tea, a blend of herbs, including licorice root. The patient was advised to discontinue consumption of the herbal tea, and at a subsequent appointment, her blood pressure was 128/73 mm Hg and her laboratory panel had improved, including serum potassium concentration of 4.1 mEq/L, PAC of 6 ng/dL, and PRA of 0.19 ng/mL/h.

Discussion:

Excessive consumption of licorice has been well documented to cause pseudohyperaldosteronism, characterized by hypertension, hypokalemia, and suppressed plasma renin and aldosterone levels. Glycyrrhizin, the active ingredient in licorice, inhibits 11β-hydroxysteroid dehydrogenase type 2, an oxidase responsible for the conversion and inactivation of cortisol to cortisone. Chronic ingestion of licorice-containing foods has been demonstrated to cause pseudohyperaldosteronism. These include soft candies, lozenges, and dietary supplements, but licorice-containing teas have been infrequently described. Based on the Naranjo probability score, our patient's hypertension appears to have been a probable licorice-induced reaction secondary to a licorice-containing tea.

Conclusions:

Herbal and dietary supplements are frequently consumed by patients without full knowledge of the contents of the products or the impact on their health. In clinical practice, when hypertension is accompanied by hypokalemia and reduced PRA and PAC, licorice consumption should be investigated and causal hypertension ruled out.

Herbal product use by older adults

In the past two decades, there has been an exponential increase in the use of medicinal herbal products around the world. In various countries, these products are classified and promoted as foods, not pharmaceuticals, which facilitate their availability on the international market without requiring a medical prescription. Since older adults (OAs) are an important and growing sector of the population in many countries, it is important to know the prevalence of their herbal product use, since many OA take herbs along with diverse quantities of prescription and over the counter medications. For this reason, it is important to be aware of the possibilities of health complications due to the concomitant use of diverse medications and herbs. OA are an especially vulnerable population, since many of the human body's physiological activities, such as renal and hepatic detoxification and clearance usually decrease with age. Additionally, information on certain herbal products is either misleading, or simply unavailable. These products may indeed be a therapeutic option, but some can be used properly only under the guidance of a health professional. Those OA taking combinations of various medications and herbal supplements are also more at risk to experience some sort of herb-drug interactions. This publication reviews selected articles related to the use of herbal products by OAs and mentions the various patterns of use and health implications of the concomitant use of herbal products and prescription medications. This topic is currently not fully understood and further research is warranted.

Factor structure of pain medication questionnaire in community-dwelling older adults with chronic pain

OBJECTIVES

This study was to develop a version of the Pain Medication Questionnaire (PMQ) specific to the elderly chronic pain population and to identify relevant subscales and items for that population. Exploratory factor analysis (EFA) was conducted to assess the factor structure of the PMQ, to eliminate items that are not appropriate for this population, and to improve ease of administration in the elderly population.

METHODS

Data were obtained through a survey administered to older adults with chronic pain who consumed opioid medications in a cross-sectional study at outpatient clinics affiliated with the Baltimore Veterans Affairs Medical Center and the University of Maryland Medical System. EFA was conducted on the PMQ in the geriatric chronic pain population, which was compared with the PMQ studies from the general chronic pain population.

RESULTS

A two-factor solution yielded Factor 1 with four items and Factor 2 with three items; 18 items did not load significantly on either factor, and only seven items loaded significantly on either factor. All of the chosen factor loadings ranged from 0.41 to 0.88.

CONCLUSION

  The findings suggest that, although a small number of the items were identified from the overall scale, they adequately explain two relatively unique factors pertaining to pain management among older adults. This preliminary study suggests that the seven-item PMQ may be useful in assessing opioid medication misuse in community-dwelling older adults with chronic pain. Future studies are needed to confirm the reliability, validity, and factor structure of this modified PMQ in the geriatric population.

The incidence of potential drug-drug interactions in elderly patients with arterial hypertension

OBJECTIVE

To assess the incidence and type of potential, clinically significant drug-drug interactions in elderly outpatients with arterial hypertension.

SETTING

Three community pharmacies in Croatia.

METHOD

Eligible patients were aged 65 or older, treated for arterial hypertension and received 2 or more drugs. Potential interactions were identified by Lexi-Interact software. The software categorized each potential interaction according to clinical significance in five groups: (A) No known interaction; (B) Specified agents may interact, but there is little to no evidence of clinical concern; (C) Specified agents may interact in a clinically significant manner. Monitoring therapy is suggested; (D) The two medications may interact in a clinically significant manner. Modification of therapy is suggested; (X) Contraindicated combination. Interactions of level C, D and X were considered clinically significant.

MAIN OUTCOME MEASURE

The incidence and type of potential drug-drug interactions.

RESULTS

There were 265 patients included in the study. Potential, clinically significant drug interactions were identified in 240 (90.6%) patients, out of which 97.9% had interactions with clinical significance C, 20.4% D, and 0.8% X. The median number of drug interactions per patient was 4. We identified 215 drug combinations with the potential to cause clinically significant interaction, out of which 83.3% had clinical significance C, 16.3% clinical significance D, and 0.4% clinical significance X.

CONCLUSION

Drug-drug interactions are common in elderly hypertensive patients. Computer-based screening could help pharmacists and physicians to recognize potential, clinically significant interactions.

Polypharmacy in older adults with cancer

The definition of "polypharmacy" ranges from the use of a large number of medications; the use of potentially inappropriate medications, which can increase the risk for adverse drug events; medication underuse despite instructions to the contrary; and medication duplication. Older adults are particularly at risk because they often present with several medical conditions requiring pharmacotherapy. Cancer-related therapy adds to this risk in older adults, but few studies have been conducted in this patient population. In this review, we outline the adverse outcomes associated with polypharmacy and present polypharmacy definitions offered by the geriatrics literature. We also examine the strengths and weaknesses of these definitions and explore the relationships among these definitions and what is known about the prevalence and impact of polypharmacy.

Pharmacologic management of the older woman undergoing surgery

Surgical intervention for both emergency and elective surgeries will increase as women live longer and maintain active lifestyles. Older women with operable conditions tolerate elective gynecologic and other nonvascular surgery with acceptable morbidity and mortality. However, increased medical comorbidities, with their associated increase in polypharmacy and perioperative risks as women age, make it important to a priori optimize perioperative medical conditions and medication management. Other considerations include assessing functional and cognitive status, since these may be impaired acutely with increased prevalence of drug use during surgical hospitalization. With aging and postmenopausal status, changes associated with aging appear to play a greater role than gender in pharmacologic responses. Surgical outcomes should be optimized to maintain and even improve women's quality of life.

Reduction of suboptimal prescribing and clinical outcome for dementia patients in a senior behavioral health inpatient unit

BACKGROUND

Suboptimal prescribing in older psychiatric patients causes iatrogenic morbidity. The objectives of this study were to compare the prevalence of suboptimal prescribing before and after admission to a geropsychiatry inpatient unit and to evaluate a possible correlation between optimal medication use and functional improvement in patients with dementia.

METHODS

The study sample comprised 118 consecutively admitted patients to a 14-bed university hospital-based geropsychiatry inpatient unit over a period of 20 months who met the DSM-IVTR criteria for an Axis I psychiatric illness and co-morbid dementia. At admission demographic information, Mini-mental State Examination (MMSE) Score, Mattis Dementia Rating Scale Score (DRS), and number of active medical illnesses were recorded. At admission and discharge the number and type of medications, number of Revised Beers Criteria (RBC) medications (a published list of potentially inappropriate medications in older adults independent of diagnoses or conditions), Global Assessment of Functioning (GAF) scores, and Scale of Functioning (SOF) scores were tabulated. chi2 tests, paired t-tests and Pearson correlations were used to test the medication prevalence and associations between measures of clinical function and other variables.

RESULTS

The mean age (standard deviation) of the sample was 81.5 (6.2) years. The mean scores on the MMSE and DRS were 22.1 (6.2) and 116.6 (18.7), respectively. From admission to discharge, the mean number of RBC medications per patient decreased significantly from 0.8 (1.1) to 0.4 (0.6). There was also a significant correlation between reduction in Beers criteria medications and improved SOF score from time of admission to time of discharge.

CONCLUSION

Suboptimal medication use is a potential source of decreased function in older patients with dementia.

Potential drug interactions in cancer patients receiving supportive care exclusively

Cancer patients at the end of life often take many medications and are at risk for drug interactions. The purpose of this study was to describe the epidemiology of potential drug interactions in cancer patients receiving supportive care exclusively. We retrospectively reviewed the charts of consecutive adult cancer outpatients attending palliative care clinics at the Princess Margaret Hospital, Toronto, Canada. Drugs were screened for interactions by the Drug Interaction Facts software, which classifies interactions by levels of severity (major, moderate, and minor) and scientific evidence (1-5, with 1=the strongest level of evidence). Among 372 eligible patients, 250 potential drug interactions were identified in 115 patients (31%, 95% confidence interval 26%-36%). The most common involved warfarin and phenytoin. Most interactions were classified as being of moderate severity (59%) and 42% of them were supported by Levels 1-3 of evidence. In multivariable analysis, increasing age (P<0.001), presence of comorbidity (P=0.001), cancer type (brain tumors, P<0.001), and increasing number of drugs (P<0.001) were associated with risk of drug interactions. Potential drug interactions are common in palliative care and mostly involve warfarin and anticonvulsants. Older patients, those with comorbid conditions, brain tumor patients, and those taking many medications are at greater risk of drug interactions.