Transcript Medication Mishaps in the Elderly Peron P, Marcum Z, Boyce R

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.
Ashley Harrison
UGA Doctor of Pharmacy Candidate
Class of 2012
Journal Club
June 2011
Level of Evidence: IB
Objective
To review articles from the 2010 calendar
year regarding medication errors or adverse
events in the elderly population
Design: Inclusion Criteria
 A MEDLINE and EMBASE search was performed to
find studies involving the following terms:
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Medication errors
Adherence
Compliance
Suboptimal prescribing
Monitoring, adverse events
Adverse withdrawal events
Therapeutic failures
Aged
Design
 5 studies were chosen to be reviewed:
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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
Potential Underprescribing
Changes In Under-treatment After Comprehensive
Geriatric Assessment:
An Observational Study
Summary
 Elderly patients were enrolled to assess the impact of
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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 undertreated
After 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
Potential Inappropriate
Prescribing
Preventing Potentially Inappropriate Medication
Use In Hospitalized Older Patients With A
Computerized Provider Order Entry Warning
System
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
Medication Adherence
Adverse Effects Of Complementary And Alternative Medicine
On Antihypertensive Medication Adherence:
Findings From The Cohort Study Of Medication Adherence
Among Older Adults
Summary
 The use of CAM was compared with adherence to antihypertensive
medications in the elderly population using the Morisky Medication
Adherence Scale (MMAS-8)
How often do you forget to take your high blood pressure medication?
How often did you miss taking your high blood pressure medication in the
past 2 weeks?
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Have you ever cut back on taking your high blood pressure medication
because you felt worse?
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Do you forget to bring medication when leaving home?
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Did you take your high blood pressure medication yesterday?
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Do you stop taking medications because problem is under control?
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Have you ever had difficulty sticking to a treatment plan?
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How often do you have difficulty remembering to take your high blood
pressure medication?
*Low adherence: Score <6
*Not low adherence: Score >6
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Results
 14.1% of patients self-reported being non-adherent
(MMAS score <6)
 26.5% used CAM to manage their hypertension
 Results 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
Medication-Related Adverse
Patient Events
Risk For Fractures With Centrally Acting Muscle Relaxants:
An Analysis Of A National Medicare Advantage Claims
Database
Summary
 The risk of facture injury was assessed for patients > 65
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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.
Medication-Related Adverse
Patient Events
Identifying And Preventing Adverse Drug Events In
Elderly Hospitalized Patients:
A Randomized Trial Of A Program To Reduce Adverse
Drug Effects
Summary
 Experimental group’s healthcare team received 1
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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 reported
Intervention group: 19.4% ADEs reported
Overall, 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
Author’s Conclusions
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
My 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.