Amie Taggart Blaszczyk

Megestrol Acetate and Mirtazapine for the Treatment of Unplanned Weight Loss in the Elderly

A rising concern among clinicians is treatment of unplanned weight loss in the elderly, especially given the predicted growth of this population over the next few decades. Unexpected weight loss in the geriatric patient worsens overall health outcomes. A variety of pharmacotherapeutic options are available for treatment; however, evidence underlying their use is limited, and none has gained approval from the United States Food and Drug Administration for this indication. At present, no guidelines support the choice of one agent over another. Although several drug interventions have been employed for this problem, megestrol acetate and mirtazapine are becoming increasingly used for appetite stimulation. These drugs represent two feasible options for geriatric patients because of their generally favorable adverse‐effect profiles and few drug interactions, but they are often misused. In a comprehensive search of the MEDLINE and International Pharmaceutical Abstracts databases, we identified all published reports on the use of megestrol acetate or mirtazapine for the treatment of weight loss and on any adverse events associated with these drugs. Special emphasis was placed on trials performed in an elderly population. Results were conflicting, most likely because of differing study designs and small numbers of patients. Megestrol acetate and mirtazapine appear to be effective for appetite stimulation and weight gain in some settings. However, applicability of the data to elderly individuals is unclear, and adverse events reported in a few of the trials and in case reports were not benign. Therefore, the use of megestrol acetate or mirtazapine for weight loss should be thoroughly evaluated on an individual basis. Pharmacotherapy should be used only after all underlying causes of weight loss are assessed and treated.

Reliability of a seminar grading rubric in a grand rounds course.

Purpose: Formal presentations are a common requirement for students in health professional programs, and evaluations are often viewed as subjective. To date, literature describing the reliability or validity of seminar grading rubrics is lacking. The objectives of this study were to characterize inter-rater agreement and internal consistency of a grading rubric used in a grand rounds seminar course. Methods: Retrospective study of 252 student presentations given from fall 2007 to fall 2008. Data including student and faculty demographics, overall content score, overall communication scores, subcomponents of content and communication, and total presentation scores were collected. Statistical analyses were performed using SPSS, 16.0. Results: The rubric demonstrated internal consistency (Cronbach’s alpha = 0.826). Mean grade difference between faculty graders was 4.54 percentage points (SD = 3.614), with ≤ 10-point difference for 92.5% of faculty evaluations. Student self evaluations correlated with faculty scores for content, communication, and overall presentation (r = 0.513, r = 0.455, and r = 0.539; P < 0.001 for all respectively). When comparing mean faculty scores to student’s self-evaluations between quintiles, students with lower faculty evaluations overestimated their performance, and those with high faculty evaluations underestimated their performance (P < 0.001). Conclusion: The seminar evaluation rubric demonstrated inter-rater agreement and internal consistency.

Visual Hallucinations Treated with the Reinitiation of Memantine in a Patient with Lewy Body Dementia

OBJECTIVE: To report on a patient with Lewy body dementia who developed worsening of hallucinations with memantine withdrawal and significant improvement with reinitiation of the drug. CASE SUMMARY: A 78-year-old man presented to a geriatric psychiatry clinic in March 2011. The patient had experienced gradual memory loss since 2007 and was diagnosed with dementia with Lewy bodies (DLB) in 2009. His medication regimen included donepezil and memantine; his cognitive and functional status appeared stable. Occasional mild visual hallucinations occurred but were not concerning to the patient or his wife. The patient did well to July 2011, when memantine became restricted within the health care institution; memantine was therefore tapered to discontinuation. From July to September 2011, the patients cognition and function appeared to decline significantly. He also began experiencing severe visual hallucinations daily. Memantine was reinitiated in September 2011 and, within days, the patient was free of hallucinations. By November 2011, his cognition and function were noted to have improved to previous status, and hallucinations were rare. DISCUSSION: Three small randomized studies and 4 case reports were found addressing the use of memantine for DLB. Both improvement and worsening of hallucinations were noted with memantine use in the case reports, but the studies showed only a small benefit in cognition. However, cognitive and psychiatric symptoms worsened when memantine was discontinued. One study found that Neuropsychiatric-Inventory scores and hallucination scores improved significantly for patients taking memantine. CONCLUSIONS: The literature investigating the use of memantine for the psychiatric symptoms of DLB is limited but there are data noting results similar to what we observed in our patient when his memantine was discontinued and reinitiated.

Bisphosphonate Use in Patients Undergoing Dialysis

Bisphosphonates are efficacious for a variety of antiosteoporotic endpoints, most notably for vertebral, nonvertebral, and hip outcomes, including fractures. Currently the prevalence of osteoporosis in patients undergoing dialysis ranges from 13% to 80%. There are very limited data on the use of bisphosphonates within this population. This review discusses the available literature regarding bisphosphonates and dialysis. Contraindication to bisphosphonates, which are cleared renally, can be justifiable based on the pharmacokinetics. However, the medication and dialysis factors that should be considered if bisphosphonates are used in these patients include the amount of drug removed per dialysis session, the molecular weight, the percent protein-bound, sieving coefficient, dialysis membrane, blood-flow rates, and dialysis-flow rates.In addition, much data on bisphosphonates and dialysis are derived from nonosteoporosis studies. Furthermore, a large portion of patients requiring dialysis are at risk for osteoporosis and subsequent fractures, and may benefit from use of bisphosphonates. However, with a dearth of knowledge, more data are needed prior to making this a routine recommendation.

HIV: a growing concern in the elderly population.

HIV infections are a growing concern in the elderly as a result of improvements in therapeutics and monitoring, which have extended the life span for this HIV-infected population. Elderly patients potentially are more complicated to treat than younger HIV-infected individuals because of comorbidities and the physiological effects of aging on pharmacokinetics and pharmacodynamics. The patient, a 67-year-old African-American HIV-infected male, presents to the transitional care unit of university-affiliated hospital refusing to take medications and undergo laboratory testing, including blood draws. This patients treatment is further complicated by poor renal function, medications with potential interactions, and a recent diagnosis of depression. This case demonstrates treatment and monitoring of an elderly patient with HIV and reveals the complications associated with this disease state. Specifically, it identifies nonadherence to medications and a lack of laboratory results, which affect the efficacy of treatment and monitoring, medication adjustments based on metabolism and renal excretion, monitoring of adverse effects of HIV and antiretroviral therapy, and comorbid conditions that may be linked to HIV and antiretroviral therapy such as depression and bone disease. Education on HIV medications, monitoring, and standards of care for pharmacists working with the geriatric population is warranted and should be emphasized as the HIV-infected elderly population continues to grow.

Treatment of Cognitive Decline and Psychiatric Disturbances Associated With Alzheimer's Dementia

Alzheimers dementia (AD) is the most common type of dementia. In addition to the cognitive and functional disturbances that happen as the disease progresses, other psychological disturbances may manifest. Depression, insomnia, anxiety, and psychosis are among several psychological conditions which can occur concomitantly with AD. These changes can result in decreased quality of life for both patients and caregivers, increase caregiver burden, and impact the decision to place a patient with AD into a long-term care facility. An evidence-based review of the literature was performed to ascertain if a specific recommendation for pharmacotherapy can be made based on current research in this specific patient population.

A Brief Review of Three Common Supplements Used in Alzheimer's Disease

Individuals with Alzheimers disease (AD) and their caregivers are using supplements in an effort to halt the progression of the disease. Individuals at risk for or fearing Alzheimers may use these supplements to try to prevent the disease. Senior care pharmacists are accessible and uniquely qualified to answer questions, make recommendations, and attempt to make drug therapy safe and effective for these individuals. With this in mind, it is important to know the data supporting (or not supporting) common supplements marketed toward those with AD. A review of efficacy and safety data, drug interactions, as well as the mechanism of action believed to benefit those with AD of three common supplements (Prevagen, Cerefolin NAC, and the omega-3 polyunsaturated fatty acid DHA), are highlighted.

Impact of empiric weight-based vancomycin dosing on nephrotoxicity and mortality in geriatric patients with methicillin-resistant Staphylococcus aureus bacteraemia

Few studies have evaluated the effect of vancomycin dosing on the health outcomes in geriatric patients. Data are needed to determine whether higher vancomycin dosing strategies are more effective in geriatric patients and/or lead to excessive rates of adverse events.

Using a Polypharmacy Simulation Exercise to Increase Empathy in Pharmacy Students

Objective. To assess whether the Jellybean Polypharmacy Simulation Exercise (JPSE) improved empathy in pharmacy students. Methods. The JPSE was given to all third-professional year pharmacy students in a required Special Populations course with pre- and post-scores on the Kiersma-Chen Empathy Scale (KCES) assessed, and open-ended questions on lessons learned from the exercise. Results. Pharmacy students showed a statistically significant increase in KCES scores after completing the JPSE. Open-ended question responses reflected personal growth and appreciation for patients managing difficult medication regimens. Conclusion. This polypharmacy simulation showed the ability to increase empathy in pharmacy students, as well as mimic a realistic experience in managing a multi-drug, multi-dose medication regimen.

COPD Exacerbation and Cholinesterase Therapy in Dementia Patients.

BACKGROUND Chronic obstructive pulmonary disease (COPD) is a nonreversible inflammatory condition of the lungs. Acetylcholine is a neurotransmitter involved in autonomic regulation of the airways, resulting in bronchoconstriction and mucous production. Cholinesterase inhibitors (ChEIs), a cornerstone therapy of dementia treatment, increase acetylcholine. Theoretically, ChEI use in patients with COPD can place patients at increased risk of exacerbation secondary to increased acetylcholine activity. METHODS A retrospective chart review was performed comparing veterans with dementia and COPD who received ChEIs with those who did not at the Veterans Affairs North Texas Health Care System. Frequency of exacerbation in the first 90 days following ChEI initiation was compared. Secondary outcomes assessed exacerbation severity and a potential protective effect of inhaled anticholinergics. RESULTS A total of 94 patients were eligible for the study; 52 received a ChEI and 42 did not. The risk of exacerbation over 90 days was higher in the ChEI users with 10 (19%) experiencing an exacerbation compared with 3 (7%) in the nonusers (P = 0.133), showing a clinically significant trend. Of the patients experiencing an exacerbation, 2 patients on ChEIs had multiple exacerbations over the 90 days. The use of inhaled anticholinergics was not found to decrease the risk of exacerbation. CONCLUSION The use of ChEIs may increase the risk of COPD exacerbation in the first 90 days of therapy in patients with dementia and COPD. This finding is clinically significant as previous studies have indicated no risk.