Ivy M. Alexander

How Can Osteoporosis Patients Benefit More from Their Therapy? Adherence Issues with Bisphosphonate Therapy

Objective: To review the evidence on adherence with bisphosphonates and evolving dosing strategies for osteoporosis treatment. Data Sources: Articles were identified by searching MEDLINE (1975–December 2005) using the following terms: osteoporosis, postmenopausal, fracture, adherence, compliance, persistence, drug therapy, bisphosphonates, alendronate, risedronate, ibandronate, and zoledronate. Additional data included bibliographies from identified articles. Study Selection and Data Extraction: All pertinent English-language articles that discussed adherence issues in patients with osteoporosis were included. Both those that reviewed overall issues of medication adherence in osteoporosis and those that focused specifically on adherence to bisphosphonates were included, as were articles that addressed strategies for overcoming nonadherence. Data Synthesis: Inadequate diagnosis and treatment of osteoporosis result in a higher risk of fractures than is necessary. Even patients who are diagnosed and beginning treatment often do not persist with their osteoporosis medication because they perceive their fracture risk to be low and, given the asymptomatic nature of osteoporosis, do not experience the benefit of symptom reduction after taking the drugs. Factors that affect adherence to osteoporosis therapy include drug costs, adverse effects, dosing frequency, disease education, patient follow-up, and patient involvement in treatment decisions. Conclusions: By considering and implementing strategies that can improve adherence and persistence, primary care providers and pharmacists (via counseling) may enhance long-term outcomes for patients with osteoporosis.

Emancipatory actions displayed by multi-ethnic women: "Regaining control of my health care".

Purpose: Despite the recognized importance of patient involvement in primary care interactions, little information describing womens needs and expectations for these interactions is available. This participatory action study was based in Critical Action Theory and designed to describe any emancipatory interests that surfaced when eight ethnically diverse women examined their interactions with primary care nurse practitioners (PCNPs) over the course of five successive focus group meetings. Data Sources: Focus group meeting transcripts, field notes, interaction notations, seating maps, and first impression summaries. Conclusions: Participants wanted to learn how to “stand up” for themselves in primary care interactions. They believed this could be accomplished by developing a positive sense of self‐esteem. Ultimately, they identified the right way to “talk back” to clinicians and created a method for regaining control of their own health care and maintaining equality in interactions with primary care clinicians. Implications for Practice: Nurse practitioners working in the primary setting are especially well situated to support self‐management and foster patient participation by women as they live with chronic disease, engage in health promotion activities, and deal with common symptomatic problems for themselves and their families.

Treating vasomotor symptoms of menopause: The nurse practitioner’s perspective

Purpose: This article reviews the pathophysiology of vasomotor symptoms (VMS) of menopause and current management options. Data sources: Current scientific literature. Conclusions: In most menopausal women, loss of ovarian function results in VMS, including hot flashes, night sweats, and mood and sleep disturbances. Hormone therapy (HT) has been the mainstay of VMS treatment for many years, but safety concerns raised by publication of the Women’s Health Initiative (WHI) results have dramatically reduced the use of this treatment. Since the WHI published its findings, attention has focused on other novel treatments for menopausal symptoms, including low‐dose oral or transdermal HT and agents such as selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors, gabapentin, and clonidine. Many women also use complementary and alternative medications to manage VMS, but little evidence from controlled clinical trials supports their efficacy. Implications for practice: The increasing number of alternative treatments for VMS requires improvement in patient–provider communication about treatment risks and benefits, individualization of treatment to meet patient needs and attitudes, and careful follow‐up to ensure adherence to potentially effective therapy. Nurse practitioners play a leading role in patient evaluation, discussions, and management to help women achieve control over bothersome VMS that dramatically impact their quality of life.

Multidisciplinary osteoporosis management of post low-energy trauma hip-fracture patients.

Purpose: The purpose of this article is to increase awareness of osteoporosis incidence in patients with hip fracture among providers and allied health professionals, to increase osteoporosis recognition and treatment in post hip‐fracture patients, and to provide guidance on how to improve continuity of care and collaboration between members of the multidisciplinary healthcare team. Data sources: Recent evidence from the literature is reviewed to identify effective management strategies for post low‐energy trauma hip‐fracture patients and prevention of future osteoporotic fracture, regardless of osteoporosis diagnosis prior to the initial fracture. Conclusions: Despite the availability of accurate screening technologies and highly efficacious antiosteoporosis medications, implementation of these measures for low‐energy trauma hip‐fracture patients remains critically low. This is because of a number of factors including hesitancy to integrate care across specialty lines, lack of reliable referral systems, and resistance to change. There is also a lack of recognition of the connection between low‐energy trauma hip fracture and osteoporosis by many healthcare professionals. Implications for practice: All members of the multidisciplinary care team are called to action to adopt osteoporosis evaluation and treatment strategies that research has shown to be effective on a larger scale in the post hip‐fracture setting.

VIRAL HEPATITIS: PRIMARY CARE DIAGNOSIS AND MANAGEMENT

Many patients in primary care settings have hepatitis. This article discusses signs and symptoms of acute hepatitis and outlines differential diagnoses. The characteristics and methods of transmission of individual hepatotropic viruses, including hepatitis A, B, C, D, E, and G/GB-C are reviewed. Serologic diagnosis of the causative agent is explained. Patient care includes sign and symptom management, medication administration, prevention of transmission to friends and family members, follow-up serologic testing, and evaluation for chronic infection. Preventive measures include vaccination and the use of immune globulin agents for hepatitis A and B. Health care providers should be aware of recent developments in the treatment of chronic infection with hepatitis B and C.

Mind–Body Therapies for Sleep Disturbances in Women at Midlife

Multiple factors contribute to sleep disturbances in women at midlife. Poor sleep is a common occurrence in women transitioning through midlife and is associated with significant morbidity. Factors that are known to disturb sleep in women at midlife include vasomotor symptoms, nocturia, sleep apnea, and stress. Stress in particular has a significant impact on sleep. Various treatments, pharmacologic and nonpharmacologic, are available to treat sleep disturbances. One nonpharmacologic option includes mind-body medicine, which encompasses several therapies. Practices within this realm have been shown to moderate the experience of stress and help restore sleep quality. Each woman’s experience of disturbed sleep and transition through midlife is unique. By having a broad awareness of all evidence-based therapeutics, the clinician is able to present a diverse set of options for women at midlife who are affected by poor sleep.