Ashley HarrisonUGA Doctor of Pharmacy Candidate

Class of 2012

Journal ClubJune 2011

Year in Review: Medication Mishaps in the Elderly

Peron P, Marcum Z, Boyce R, Hanlon J, Handler S, et al. The American Journal of Geriatric Pharmacotherapy. 2011

Feb; 1-10.

Level of Evidence: IB

To review articles from the 2010 calendar year regarding

medication errors or adverse events in the elderly population

Objective

Design: Inclusion Criteria

A MEDLINE and EMBASE search was performed to find studies involving the following terms: Medication errors Adherence Compliance Suboptimal prescribing Monitoring, adverse events Adverse withdrawal events Therapeutic failures Aged

Design

5 studies were chosen to be reviewed: Potential under-prescribing

Changes In Under-treatment After Comprehensive Geriatric Assessment: An Observational Study

Inappropriate prescribing Preventing Potentially Inappropriate Medication Use In

Hospitalized Older Patients With A Computerized Provider Order Entry Warning System

Medication adherence Adverse Effects Of Complementary And Alternative Medicine On

Antihypertensive Medication Adherence: Findings From The Cohort Study Of Medication Adherence Among Older Adults

Medication-related adverse events Risk For Fractures With Centrally Acting Muscle Relaxants: An

Analysis Of A National Medicare Advantage Claims Database Identifying And Preventing Adverse Drug Events In Elderly

Hospitalized Patients: A Randomized Trial Of A Program To Reduce Adverse Drug Effects

Changes In Under-treatment After Comprehensive Geriatric Assessment:

An Observational Study

Potential Underprescribing

Summary

Elderly patients were enrolled to assess the impact of comprehensive geriatric assessment on the prevalence of undertreatment in this population

“Undertreated”- lacking drugs indicated for 1 of 10 commonly undertreated diseases

Before CGA: 32.9% were considered undertreatedAfter CGA: 22.3% were considered undertreated

(P <0.01)These rates are even higher in the U.S. (50-65%

undertreated)

Conclusion

CGA reduces suboptimal prescribing in the aged population

Preventing Potentially Inappropriate Medication Use In

Hospitalized Older Patients With A Computerized Provider Order

Entry Warning System

Potential Inappropriate Prescribing

Summary

Computerized Provider Order Entry (CPOE) system with clinical decision support (CDS) was implemented to assess its effect on orders for potentially inappropriate medications in elderly patients

Before CPOE: average rate of 11.56% PIMs ordered per day

After CPOE: 9.94% (P <0.001)There were no changes in the rate of

medication orders not targeted by the system

Conclusion

Specific CDS alerts within a CPOE system used in patients > 65 y/o decreased the number of

orders for potentially inappropriate medications

Adverse Effects Of Complementary And Alternative Medicine On

Antihypertensive Medication Adherence:

Findings From The Cohort Study Of Medication Adherence Among Older

Adults

Medication Adherence

Summary

The use of CAM was compared with adherence to antihypertensive medications in the elderly population using the Morisky Medication Adherence Scale (MMAS-8)

1. How often do you forget to take your high blood pressure medication?

2. How often did you miss taking your high blood pressure medication in the past 2 weeks?

3. Have you ever cut back on taking your high blood pressure medication because you felt worse?

4. Do you forget to bring medication when leaving home?5. Did you take your high blood pressure medication yesterday?6. Do you stop taking medications because problem is under control?7. Have you ever had difficulty sticking to a treatment plan?8. How often do you have difficulty remembering to take your high

blood pressure medication?*Low adherence: Score <6*Not low adherence: Score >6

Results

14.1% of patients self-reported being non-adherent (MMAS score <6)

26.5% used CAM to manage their hypertensionResults varied upon race:

30.5 blacks vs. 24.7% of whites reported CAM use (P<0.005)

18.4% of blacks vs. 12.3% of whites had low antihypertensive medication adherence (P<0.001)

The risk of CAM use affecting medication adherence was higher in blacks than in whites

Conclusions

CAM use is more common in older African American patients

CAM use may have a negative impact on antihypertensive medication adherence

It is essential to question patients about the use of non-prescription medications, since many do not self-report CAM use

Risk For Fractures With Centrally Acting Muscle Relaxants:

An Analysis Of A National Medicare Advantage Claims Database

Medication-Related Adverse Patient Events

Summary

The risk of facture injury was assessed for patients > 65 y/o who were prescribed skeletal muscle relaxants

Patients in the experimental group had at least 1 ICD-9 code for fracture and at least 1 prescription within 3 months before the fracture event

Patients taking muscle relaxants had increased risk of fracture (OR 1.4, 95% CI)

The use of > 2 muscle relaxants did not significantly increase the risk of fracture compared to a muscle relaxant used alone

Long-acting and short-acting benzodiazepines also increased the risk, especially when combined with a muscle relaxant (OR 2.66, 1.86 respectively, 95% CI)

Conclusions

Skeletal muscle relaxants are associated with falls and fractures and should therefore be placed on the Beers list as PIMs

When > 2 drugs acting on the CNS are used in combination, the risk for fracture is increased.

Identifying And Preventing Adverse Drug Events In Elderly

Hospitalized Patients: A Randomized Trial Of A Program To Reduce Adverse Drug Effects

Medication-Related Adverse Patient Events

Summary

Experimental group’s healthcare team received 1 week of educational intervention regarding geriatric pharmacotherapy topics

There was a 2 week follow-up period in both the experimental and control groups in which ADEs were recorded. These were evaluated by a team of healthcare professionals

Control group: 26.1% ADEs reportedIntervention group: 19.4% ADEs reportedOverall, 28% of the ADEs were found to be

preventable

Conclusion

Implementing education intervention in healthcare teams decreased the number of adverse drug events reported in hospitalized patients in France

The data found in these studies is instrumental in helping healthcare professionals understand medication errors and adverse drug events, as well as how to prevent them

This information may also help to guide further research and clinical practices in the future

Author’s Conclusions

The risk of medication errors and mishaps is particularly high in the elderly population due to polypharmacy and decline in the function of multiple body systems.

Any preventative measures that can be taken to ensure the safety of these patients and decrease the number of medication errors is beneficial and should be implemented.

My Conclusions