Arjun Poudel

Polypharmacy among inpatients aged 70 years or older in Australia.

Objectives: To investigate medication changes for older patients admitted to hospital and to explore associations between patient characteristics and polypharmacy.

Frailty: a key indicator to minimize inappropriate medication in older people.

Older populations are more likely to have multiple co-morbid diseases that require multiple treatments, which make them a large consumer of medications. As a person grows older, their ability to tolerate medications becomes less due to age-related changes in pharmacokinetics and pharmacodynamics often heading along a path that leads to frailty. Frail older persons often have multiple co-morbidities with signs of impairment in activities of daily living. Prescribing drugs for these vulnerable individuals is difficult and is a potentially unsafe activity. Inappropriate prescribing in older population can be detected using explicit (criterion-based) or implicit (judgment-based) criteria. Unfortunately, most current therapeutic guidelines are applicable only to healthy older adults and cannot be generalized to frail patients. These discrepancies should be addressed either by developing new criteria or by refining the existing tools for frail older people. The first and foremost step is to identify the frail patient in clinical practice by applying clinically validated tools. Once the frail patient has been identified, there is a need for specific measures or criteria to assess appropriateness of therapy that consider such factors as quality of life, functional status and remaining life expectancy and thus modified goals of care.

Age-related changes in hepatic function: An update on implications for drug therapy

The accumulation of deficits with increasing age results in a decline in the functional capacity of multiple organs and systems. These changes can have a significant influence on the pharmacokinetics and pharmacodynamics of prescribed drugs. Although alterations in body composition and worsening renal clearance are important considerations, for most drugs the liver has the greatest effect on metabolism. Age-related change in hepatic function thereby causes much of the variability in older people’s responses to medication. In this review, we propose that a decline in the ability of the liver to inactivate toxins may contribute to a proinflammatory state in which frailty can develop. Since inflammation also downregulates drug metabolism, medication prescribed to frail older people in accordance with disease-specific guidelines may undergo reduced systemic clearance, leading to adverse drug reactions, further functional decline and increasing polypharmacy, exacerbating rather than ameliorating frailty status. We also describe how increasing chronological age and frailty status impact liver size, blood flow and protein binding and enzymes of drug metabolism. This is used to contextualise our discussion of appropriate prescribing practices. For example, while the general axiom of ‘start low, go slow’ should underpin the initiation of medication (titrating to a defined therapeutic goal), it is important to consider whether drug clearance is flow or capacity-limited. By summarising the effect of age-related changes in hepatic function on medications commonly used in older people, we aim to provide a guide that will have high clinical utility for practising geriatricians.

Potentially Inappropriate Prescribing in Older Patients Discharged From Acute Care Hospitals to Residential Aged Care Facilities

Background: The frequency of prescribing potentially inappropriate medications (PIMs) in older patients remains high despite evidence of adverse outcomes from their use. Little is known about whether admission to hospital has any effect on appropriateness of prescribing. Objectives: This study aimed to identify the prevalence and nature of PIMs and explore the association of risk factors for receiving a PIM. Methods: This was a prospective study of 206 patients discharged to residential aged care facilities from acute care. All patients were at least 70 years old and were admitted between July 2005 and May 2010; their admission and discharge medications were evaluated. Results: Mean patient age was 84.8 ± 6.7 years; the majority (57%) were older than 85 years, and mean (SD) Frailty Index was 0.42 (0.15). At least 1 PIM was identified in 112 (54.4%) patients on admission and 102 (49.5%) patients on discharge. Of all medications prescribed at admission (1728), 10.8% were PIMs, and at discharge, of 1759 medications, 9.6% were PIMs. Of the total 187 PIMs on admission, 56 (30%) were stopped and 131 were continued; 32 new PIMs were introduced. Of the potential risk factors considered, in-hospital cognitive decline and frailty status were the only significant predictors of PIMs. Conclusions: Although admission to hospital is an opportunity to review the indications for specific medications, a high prevalence of inappropriate drug use was observed. The only associations with PIM use were the frailty status and in-hospital cognitive decline. Additional studies are needed to further evaluate this association.

Prescribing for older people discharged from the acute sector to residential aged-care facilities

For frail older people, admission to hospital is an opportunity to review the indications for specific medications. This research investigates prescribing for 206 older people discharged into residential aged care facilities from 11 acute care hospitals in Australia. Patients had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean of 7.2 regular medications at admission to hospital and 8.1 medications on discharge, with hyper‐polypharmacy (≥10 drugs) increasing from 24.3% to 32.5%. Many drugs were preventive medications whose time until benefit was likely to exceed the expected lifespan. In summary, frail patients continue to be exposed to extensive polypharmacy and medications with uncertain risk–benefit ratio.

Oncology pharmacy practice in a teaching hospital in Nepal.

Objective. To highlight the patient care activities performed by pharmacists during their ward rounds in medical oncology ward of a tertiary care hospital in western region of Nepal. Methods. The study was conducted for 3 months. Two pharmacists joined the clinicians and nurses in the ward rounds every morning as a member of healthcare team. The data used in this study was obtained from different documented files in hospital and were analyzed as per study objectives. Results. During 3 months (May 20, 2008 to August 20, 2008), pharmacists provided answers to eight queries asked by clinicians and nurses for the patient care purpose. During the same period pharmacists detected four cases of medication errors and provided suggestions on them. A total of 30 adverse drug reaction (ADR) reports were reported to the regional pharmacovigilance center during the study time. Altogether there were 84 types of adverse drug reaction seen on those patients. Most of them were related to hematological system. Conclusion. The study evaluated the drug information provided by pharmacists, spontaneous reporting of ADRs by the pharmacists, and their intervention on treatment plan of patients during ward round. This suggests pharmacists can play a significant role on patient care when he or she joins round with other healthcare personnel in the oncology ward. J Oncol Pharm Practice (2010) 16: 75—79.

Potentially inappropriate prescribing in older patients admitted to acute care hospitals and discharged to residential aged care facilities

Paper Session Paper Abstracts Plenary Thursday, May 15 11:00 am – 12:00 pm P1 Encore Presentation Against All Odds: Results from the ZEST Trial in Long Term Care Residents S. Greenspan, S. K. Perera, M. Ferchak, G. Langmann, D. Nace, N. M. Resnick. University of Pittsburgh, Pittsburgh, PA. Supported By: NIH R01 AG028068 (PI: Dr. Susan Greenspan), Pittsburgh Older American’s Independence Center P30 AG024827 Background: Although nearly 85% of long term care (LTC) residents have osteoporosis, the pivotal trials systematically exclude frail, functionally-impaired women. The goal of ZEST (Zoledronic acid in frail Elders to STrengthen bone) was to examine the safety and efficacy of a single dose of zoledronic acid in LTC residents. Methods: This 2-year, double-blind, NIH-funded RCT included women LTC residents with life expectancy of ≥2 years who were not on an antiresorptive agent despite having osteoporosis (BMD or fracture). We included residents with cognitive impairment and immobility. All subjects received a single dose of zoledronic acid 5 mg or placebo IV and daily calcium and vitamin D. The primary outcomes were 12-month changes in hip and spine BMD. Secondary outcomes were 24 month BMD changes and safety. Innovations included a mobile laboratory to examine BMD onsite and electronic surveillance system to collect SAEs. We used linear mixed models for BMD analyses. Results: We randomized 181 women (mean age=85.4). There were no baseline differences between groups in age, BMI, calcium/ vitamin D intake, BMD, activities of daily living, or cognitive or mental health. The active treatment group included more women with falls and slow gait speed. 92% of subjects completed 12 months; 67% completed 24 months. BMD percent changes at the total hip, femoral neck and spine were significantly greater in the active treatment group compared with the placebo group at 12 and 24 months (all p< 0.01, table), with 12 month absolute differences of 3.2 percentage points at the total hip and 1.8 at the spine. There were no significant differences in SAEs or deaths. Conclusions: This trial of single dose zoledronic acid for osteoporosis in cognitively impaired, frail osteoporotic women is the first to demonstrate that it is safe and effective in preserving/improving skeletal integrity over 2 years. Future studies are needed to examine fracture reduction. Percent change ± standard error in bone mineral density at the spine, total hip and femoral neck *p<0.05, ** p< 0.01 within group change from baseline P2 Encore Presentation TIP Intervention to Reduce Multi-drug Resistance and Infections in Nursing Home Residents with Indwelling Devices: A ClusterRandomized Trial L. Mody, S. L. Krein, S. Saint, L. Min, A. Montoya, B. Lansing, S. E. McNamara, K. Symons, J. Fisch, E. Koo, R. A. Rye, A. Galecki, M. Kabeto, J. T. Fitzgerald, R. Olmsted, C. A. Kauffman, S. Bradley. 1. Medical School, University of Michigan, Ann Arbor, MI; 2. VA Ann Arbor Healthcare System, Ann Arbor, MI; 3. School of Public Health, University of Michigan, Ann Arbor, MI; 4. Long Term Care, Infection Prevention and Control Consultant, Hemlock, MI; 5. St. Joseph Mercy Health System, Ann Arbor, MI. Supported By: VA Healthcare System Geriatric Research Education and Clinical Care Center (GRECC, Mody, Bradley), NIA-Pepper Center (Mody), NIH (K23AG028943; R01AG032298 Mody, Krein, Saint, Galecki, Bradley; and R01AG041780 Mody, Min), AHRQ (R18HS019979 Mody). The authors would like to thank Gojo Industries for donation of personal use hand sanitizer bottles. BACKGROUND: Nursing home (NH) residents with indwelling devices such as urinary catheters and feeding tubes are at high risk for colonization and infection with multidrug-resistant organisms (MDROs). METHODS: In a cluster-randomized interventional trial, we evaluated the effect of a multi-modal targeted intervention in reducing MDRO prevalence and device-associated infections among NH residents with urinary catheters or feeding tubes in 12 NHs in Southeast Michigan (6 intervention & 6 control). The intervention included: 1) preemptive barrier precautions; 2) active surveillance for MDROs and infections; 3) hand hygiene promotion; and 4) staff education. Microbiological samples and clinical infection data were obtained at enrollment, at 15 days, and monthly thereafter. Data were adjusted using mixed-effect multi-level Poisson regression models for facility-level clustering and resident-level variables. RESULTS: A total of 418 NH residents with indwelling devices (203 intervention group vs. 215 control group) were enrolled over three years with 34,174 device-days and 6,557 anatomic sites sampled (17,490 device-days and 3,283 samples in intervention group vs. 16,684 device-days and 3,274 samples in control group). There were no significant differences in average duration of follow-up, comorbidity or functional status between intervention and control groups. MDROs detected in nares, groin, rectum, and wounds in the intervention group were 23% lower using mixed-effect multi-level Poisson regression models adjusted for facility-level clustering and resident-level covariates (P = 0.02). Cluster and covariate-adjusted Cox proportional hazard ratios for first and all (including recurrent) clinically-defined CAUTI were 0.54 (95% CI, 0.30 0.97; P = 0.039) and 0.69 (95% CI, 0.49 0.99; P = 0.045). CONCLUSION: Our multi-modal targeted intervention significantly reduced MDRO prevalence and clinically-defined CAUTI rates in NH residents with indwelling devices. P3 Do Unto Others: Doctors’ Personal End-of-life Resuscitation Preferences and Their Attitudes Towards Advance Directives V. Periyakoil, H. C. Kraemer, E. Neri. 1. Medicine, Stanford University School of Medicine, Stanford, CA; 2. Medicine, VA Palo Alto Health Care System, Palo Alto, CA. Supported By: Acknowledgements: Dr. Periyakoil’s work is supported in part by National Institutes of Health Grants RCA115562A and 1R25MD006857–01 and the Department of Veterans Affairs. Background: End-of-life care in the US is increasingly fragmented due to high-intensity interventions provided to seriously ill

Telepharmacy: a pharmacist’s perspective on the clinical benefits and challenges

The use of information and telecommunication technologies has expanded at a rapid rate, which has a strong influence on healthcare delivery in many countries. Rural residents and communities, however, often lack easy access to healthcare services due to geographical and demographical factors. Telepharmacy, a more recent concept that refers to pharmaceutical service provision, enables healthcare services, such as medication review, patients counseling, and prescription verification, by a qualified pharmacist for the patients located at a distance from a remotely located hospital, pharmacy, or healthcare center. Telepharmacy has many recognizable benefits such as the easy access to healthcare services in remote and rural locations, economic benefits, patient satisfaction as a result of medication access and information in rural areas, effective patient counseling, and minimal scarcity of local pharmacist and pharmacy services. Telepharmacy undoubtedly is a great concept, but it is sometimes challenging to put into practice. Inherent to the adoption of these practices are legal challenges and pitfalls that need to be addressed. The start-up of telepharmacy (hardware, software, connectivity, and operational cost) involves considerable time, effort, and money. For rural hospitals with fewer patients, the issue of costs appears to be one of the biggest barriers to telepharmacy services. Moreover, execution and implementation of comprehensive and uniform telepharmacy law is still a challenge. A well-developed system, however, can change the practice of pharmacy that is beneficial to both the rural communities and the hospitals or retail pharmacies that deliver these services.

Algorithm of medication review in frail older people: Focus on minimizing the use of high-risk medications

Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high‐risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high‐risk medications.

Initiation of social pharmacy research in Nepal: our experiences.

Nepal experiences several medicine-use problems like any other developing country. In the recent years, there have been initiatives to introduce the concept of social pharmacy in Nepal, and there has been only a limited research in this area. The staff members at the Manipal College of Medical Sciences, Pokhara have shown keen interest in initiating several social pharmacy-related researches in the country. The members of this institute have been collaborating with two international universities, namely Universiti Sains Malaysia located in Malaysia and Chulalongkorn University located in Thailand, to get academic and technical supports. In this manuscript, the authors share their experiences in initiating social pharmacy research in the country. Authors have also mentioned the priority areas of social pharmacy research in Nepal and the importance of initiating this concept in the country.