Mark Monane

The effects of initial drug choice and comorbidity on antihypertensive therapy compliance: results from a population-based study in the elderly.

Approximately half of all elderly patients have elevated blood pressure, and proper treatment of this disorder leads to decreased cardiovascular morbidity in patients 65 and older. This study examined the effect of initial drug choice and comorbidity on medication compliance. We conducted a retrospective follow-up of 8643 outpatients aged 65 to 99 with newly prescribed antihypertensive therapy (AHT) from 1982 to 1988 in the New Jersey Medicaid and Medicare programs. Compliance was measured in terms of the number of days in which AHT was available to the patient during the 12 months following the initiation of therapy. Odds ratios (OR) and 95% confidence intervals (CI) for the outcome of good compliance (> or =80%) were calculated. In a logistic regression model, good compliance (> or =80%) was significantly associated with use of newer agents such as angiotensin converting enzyme inhibitors (OR 1.9, 95% CI 1.6 to 2.2) and calcium channel blockers (OR 1.7, 95% CI 1.5 to 2.1) as compared to thiazides, the presence of comorbid cardiac disease (OR 1.2, 95% CI 1.1 to 1.2), and multiple physician visits (OR 2.2, 95% CI 1.8 to 2.5). Good compliance was inversely associated with use of multiple pharmacies (OR 0.4, 95% CI 0.4 to 0.5) and number of medications prescribed overall (OR 0.8, 95% CI 0.7 to 0.9). Drug choice, comorbidity, and health services utilization were significantly associated with AHT compliance and represent important considerations in the management of high blood pressure. Noncompliance may be an important cause of treatment failure in elderly hypertensives.

Treatment for glaucoma: adherence by the elderly.

OBJECTIVES The purpose of this study was to determine the extent of nonadherence to treatment for glaucoma among elderly patients. METHODS This was a retrospective cohort study of 2440 patients older than age 65 who were enrolled in the New Jersey Medicaid Program and who were newly initiated on a topical agent for the treatment of glaucoma. Two patient-specific measures of nonadherence were employed: (1) no filled prescription for any glaucoma medication over a 12-month period after the initiation of therapy and (2) number of days without therapy for glaucoma during this 12-month period. RESULTS By the first measure, 569 patients (23%) were found to be nonadherent. The mean number of days without therapy during the study year was 112. Factors associated with nonadherence included the use of glaucoma medication requiring more than 2 administrations per day and the presence of multiple other medications in the patients drug regimen. Patients started on multiple glaucoma medication were more adherent than those started on a single agent. Age and sex were not found to be predictors of nonadherence. CONCLUSIONS Substantial nonadherence was found to be common in this population. More attention to the issue of nonadherence could result in important benefits in the preservation of sight.

Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race.

OBJECTIVES This study measured compliance and related demographic factors in a retrospective cohort of 4068 elderly outpatients newly starting antihypertensive therapy from 1982 through 1988. METHODS Logistic regression modeling of data from the New Jersey Medicaid program was used. RESULTS These patients filled antihypertensive prescriptions covering an average of only 179 days in the 365-day follow-up period (49%) Good compliance (> or = 80%) was associated with advanced age (odds ratio [OR] = 2.12, for patients 85 or older) and White race (OR = 0.55 for Blacks). There was no relationship between compliance and gender. CONCLUSIONS Despite the efficacy of antihypertensive therapy in preventing cardiovascular morbidity, such high rates of noncompliance may contribute to suboptimal patient outcomes.

Breast Cancer Screening for Elderly Women with and without Comorbid Conditions: A Decision Analysis Model

OBJECTIVE To determine whether breast cancer screening extends life for women aged 65 years or more with and without comorbid medical conditions. SETTING A provider-patient encounter. DESIGN A decision analysis of the utility of screening for breast cancer. MEASUREMENTS Clinical examination and mammography among four groups of women aged 65 to 85 or more years: average health, mild hypertension, congestive heart failure, and average-health black women. The effects of screening were estimated using the best quality data available. RESULTS Screening saved life at all ages among patients studied. Savings were highest for black women and decreased with increasing age and comorbidity. Screening all average-health women aged 65 or more saved 67,912 years of life. For women who had cancer, screening extended life by 617 days for average-health women between 65 and 69 years of age and 178 days for those aged 85 years or more. Perioperative mortality and test characteristics had little effect on the results. The risks equaled the benefits of screening only when operative mortality was between 27% and 62%. The marginal costs of screening during a routine office visit were

Antihypertensive Drug Therapy and the Initiation of Treatment for Diabetes Mellitus

138 and increased with advancing age and decreasing test specificity. Benefits persisted after adjustment for changes in long-term quality of life; however, for women aged 85 years and older (with and without comorbidities), the short-term morbidity of anxiety or discomfort associated with screening may have outweighed the benefits. CONCLUSION No inherent reason exists to impose an upper-age limit for breast cancer screening; however, more data are needed on womens preferences for screening strategies.

Thiazide diuretics and the initiation of anti-gout therapy

Although several antihypertensive medications have been associated with impaired glucose tolerance [1], thiazide diuretics have received the most attention in this regard. Since the introduction of chlorothiazide in 1957, several cases have been reported in which thiazide diuretics were associated with glucose intolerance [2-5]. In addition, many clinical studies have provided information on the effects of thiazide diuretics on glucose homeostasis. The Veterans Administration Cooperative Study Group on Antihypertensive Agents [6] found that hydrochlorothiazide increased the average fasting plasma glucose level by approximately 0.3 mmol/L after 10 weeks of treatment. In the Systolic Hypertension in the Elderly Program study [7], the treatment group showed an increase of 0.4 mmol/L in mean serum glucose levels over the baseline level after 1 year of thiazide diuretic therapy, whereas the placebo group showed an increase of 0.1 mmol/L. In the study conducted by the European Working Party on Hypertension in the Elderly [8], the thiazide treatment group showed an increase of 0.5 mmol/L in the fasting serum glucose level after 2 years, whereas the placebo group showed a decrease of 0.2 mmol/L (P < 0.001). In a randomized, crossover study of 50 patients, Pollare and coworkers [9] found that, when compared with placebo, hydrochlorothiazide reduced insulin-stimulated glucose uptake in patients with essential hypertension after 18 weeks of treatment. In contrast, patients treated with captopril showed improved carbohydrate metabolism, including an increase in insulin-stimulated glucose uptake, when compared with placebo recipients. Previous efforts to quantify the clinical risk for development of hyperglycemia requiring treatment in patients taking various antihypertensive regimens have been limited by the relative infrequency of this event and the limited range of antihypertensive agents used in large clinical trials [10]. For the same reasons, the risks of different agents have not been adequately compared. To address these issues, we conducted a casecontrol study of 11 855 New Jersey Medicaid enrollees newly started on hypoglycemic therapy. Methods Sources of Data The study sample was drawn from the state of New Jerseys Medicaid program for the years 1981 to 1990. Enrollment in the program was ascertained through the Medicaid eligibility file, which identifies all program participants, their dates of coverage, and demographic characteristics including age, gender, and race. Data on medication use were taken from the Medicaid pharmacy claims file, which contains information on all prescriptions filled by Medicaid recipients, including the National Drug Code and the date dispensed. Medications of interest were identified using the National Drug Code specific for each agent. Hospitalization data for all Medicaid recipients were also ascertained. Medicaid recipients who were eligible to receive Medicare benefits (crossover enrollees) were identified to acquire full information on utilization of hospital services. Medicaid covers payment for medications for these Medicare recipients, which enabled us to ascertain all prescription information for this group. Case Patients Case patients were Medicaid enrollees 35 to 99 years of age who filled a first prescription for a hypoglycemic agent between 1981 and 1990. All oral hypoglycemic medications and insulin preparations were included. The date of the first prescription for a hypoglycemic medication was defined as the index date. To ensure that study patients were active users of the Medicaid system, each case patient was required to be continuously eligible in the program for at least 120 days before the index date and to have filled a prescription for at least one drug of any kind during this period. No claims for a hypoglycemic agent could be made before the index date. Drug claims were searched back to 1981 to ensure that case patients and controls had not previously filled a prescription for a hypoglycemic agent. Of the 35 202 patients who filled a first prescription for a hypoglycemic agent during the defined study period, 443 had deficient eligibility records, and 4753 did not meet the specified age criteria. The additional requirement that case patients be continuously enrolled in Medicaid during the 120 days before the index date eliminated 9292 persons. Another 8859 patients were excluded from the case group because they had not filled a prescription for any other drug during the 120 days preceding the index date. The final case group included 11 855 patients. Controls We identified controls by selecting a random sample of Medicaid enrollees who met the same criteria for eligibility and use of the health care system as did case patients but who had not filled a prescription for a hypoglycemic agent on or before a randomly assigned index date. One control was randomly selected for each case. Definitions of Antihypertensive Drug Use To characterize current exposure to antihypertensive agents, all prescriptions filled during the 120 days before the index date were reviewed for both case patients and controls. Medications of principal interest included thiazide diuretics; angiotensin-converting enzyme inhibitors; centrally acting antiadrenergic agents; peripherally acting antiadrenergic agents; -blockers; calcium-channel blockers; and vasodilators. Categorization of patients taking multiple-agent regimens representing more than one category of antihypertensive agent was based on whether the regimen did or did not contain a thiazide diuretic. Drug-exposure categories were mutually exclusive so that patients were either characterized as exposed to a single category of antihypertensive therapy or placed in one of the multiple-category groups, but not both. Three time windows of exposure before the index date were created: 1 to 45 days, 1 to 90 days, and 91 to 120 days. A patient was considered to be currently exposed to an agent if he or she filled a prescription for a medication of interest in the 45 days before the index date. This was the exposure window of primary interest. In addition, we examined records of patients who filled a prescription for a medication of interest 1 to 90 days before the index date and 91 to 120 days before the index date to study people with evidence of a more prolonged duration of exposure. Covariates Because other medications can also directly and indirectly affect glucose metabolism, we measured exposure to potassium supplements, potassium-sparing diuretics, oral glucocorticoids, estrogen-containing compounds, and niacin. In addition, exposure status for these agents was characterized according to the previously defined exposure windows. Other covariates included demographic variables (age, gender, race, residence in a nursing home) the number of days hospitalized, and the number of prescriptions filled in the 120-day period before the index date. Statistical Analysis Differences in categorical variables between case patients and controls were assessed with chi-square tests. Relative risks for new use of a hypoglycemic agent within each exposure category were estimated from odds ratios calculated by unconditional logistic regression [11] using the SAS CATMOD program [12]. For these analyses, the reference category was the absence of exposure to any antihypertensive medication. Models were constructed with patients characterized according to the study definitions of duration of exposure (current exposure or exposure of more prolonged duration). Covariates in the models included age, gender, race, nursing home residency, number of days in the hospital, number of drug claims, glucocorticoid exposure, potassium supplementation, estrogen exposure, and niacin exposure. Because of temporal trends in the pattern of antihypertensive drug prescribing [13], the study sample was stratified according to index date (pre-1985 or 1985 to 1990), and models were constructed for each subsample. Confidence intervals (CIs) for the estimated odds ratios and significance tests for differences between individual odds ratios were calculated using the estimated standard errors. To control for potential surveillance bias (that is, the possibility that patients receiving antihypertensive agents may have had closer medical supervision and may have had more laboratory tests than patients not receiving antihypertensive therapy) and to make the case and control groups more comparable, we did a separate analysis of the 8005 current users of antihypertensive medications (4794 case patients and 3211 controls). In these models, current exposure to thiazide diuretics was the reference exposure. This model also included the same potential confounding variables mentioned above. Results We found no consistent trend when examining the relation between age and the likelihood of starting a hypoglycemic medication (Table 1) in the age range studied. Patients 55 to 74 years of age were more likely to be started on a hypoglycemic agent than patients 35 to 54 years of age, although no significant difference was found between patients 75 years of age or older and patients 35 to 54 years of age. No significant differences in gender distribution were observed between case patients and controls. Blacks and other non-whites were more likely to be started on hypoglycemic therapy than whites. Patients in nursing homes were less likely to start hypoglycemic therapy than noninstitutionalized patients. Patients who had a greater number of hospital days or who filled more prescriptions were more likely to be started on a hypoglycemic medication. No relation was found between index date (pre-1985 or 1985 to 1990) and the likelihood of being started on hypoglycemic therapy. Table 1. Characteristics of the Study Sample and Their Relation to Starting a Hypoglycemic Medication The relative risk for the initiation of hypoglycemic therapy was significantly increased among patients who were current users

Neuroleptic drug exposure and treatment of parkinsonism in the elderly: a case-control study.

While physiologic and epidemiologic evidence link diuretic therapy with hyperuricemia, no previous study has quantified the risk for initiation of treatment specific for hyperuricemia or gout among elderly patients taking thiazide diuretics. We performed a retrospective cohort study of 9249 enrollees aged 65 or older in the New Jersey Medicaid program who were newly started on an antihypertensive medication from November 1981 through February 1989 and who had no prior use of anti-gout therapy (allopurinol, colchicine, or a uricosutic) during the preceding one-year period. We used Cox proportional hazards analysis to determine the risk for the initiation of anti-gout therapy in patients using various antihypertensive treatment regimens relative to no antihypertensive exposure. Patient follow-up extended for up to two years. Antihypertensive exposure was characterized over the entire period of follow-up according to the following categories: thiazide diuretic therapy alone; non-thiazide antihypertensive therapy; thiazide diuretic therapy in combination with any non-thiazide antihypertensive agent(s); and no antihypertensive use. Antihypertensive exposure was entered into the model as a time-varying covariate. Estimates of risk were adjusted for age, sex, race, nursing home residence, number of prescriptions filled, intensity of physician use, hospitalization history, and year of antihypertensive treatment initiation. The adjusted relative risk for the initiation of anti-gout therapy was 1.00 (95% CI, 0.65-1.53) for non-thiazide antihypertensive therapy alone, 1.99 (95%, CI, 1.21-3.26) for thiazide diuretic therapy, and 2.29 (95% CI, 1.55-3.37) for thiazide diuretic therapy in combination with any non-thiazide agent(s). Risk for anti-gout therapy was significantly increased for thiazide doses of > or = 25 mg/day (in hydrochlorothiazide equivalents); no significant increase in risk was seen for lower doses. We conclude that use of thiazide diuretics in doses of 25 mg/day or higher is associated with a significantly increased risk for initiation of anti-gout therapy. Such treatment may reflect the occurrence of clinical sequelae of diuretic-induced hyperuricemia or the inappropriate treatment of asymptomatic hyperuricemia.

Epidemiologic and diagnostic aspects of bacteriuria: a longitudinal study in older women.

PURPOSE Despite the widespread use of neuroleptic medications for the elderly, little is known about the frequency of treatment for drug-induced parkinsonian syndromes in this age group, particularly with L-dopa-type drugs, which are more appropriate for the treatment of true idiopathic Parkinsons disease. PATIENTS AND METHODS We identified 3,512 patients aged 65 to 99 enrolled in a large state Medicaid program who were newly prescribed a drug to treat parkinsonian symptoms. Controls were comparable program enrollees of similar age who had not been prescribed an antiparkinsonian drug. In a case-control study, we evaluated the use of neuroleptic drugs in the 90 days before initiation of antiparkinsonian therapy. RESULTS Patients taking neuroleptics were 5.4 times more likely to begin antiparkinsonian medication than were nonusers (95% confidence interval [CI] 4.8 to 6.1). They also had a greater than two-fold increase in risk of beginning therapy with a dopaminergic drug specific for idiopathic Parkinsons disease, not generally indicated for treatment of drug-induced parkinsonism (adjusted odds ratio 2.2, 95% CI 1.9 to 2.7). Clear dose-response relationships were demonstrated, as were differences among neuroleptics. Among all patients started on dopaminergic drugs in this population, 37% of such therapy was attributable to prior neuroleptic use. Continuation of the neuroleptic persisted in 71% of patients so treated. CONCLUSION Neuroleptic use is a common cause of extrapyramidal dysfunction in the elderly, and the side effect is frequently treated by adding an anticholinergic or dopaminergic drug to the regimen. The use of anticholinergic drugs presents risks of additional drug side effects; the use of dopaminergic drugs, generally not appropriate for drug-induced parkinsonian syndrome, suggests that extrapyramidal neuroleptic side effects may often be mistaken for idiopathic Parkinsons disease in older patients.

Aging, Comorbidity, and Reduced Rates of Drug Treatment for Diabetes Mellitus

OBJECTIVE: To examine month‐by‐month variability of bacteriuria in a cohort of older women and to evaluate the performance of rapid diagnostic tests commonly used to indicate the presence of significant bacteriuria.

The impact of sedative-hypnotic use on sleep symptoms in elderly nursing home residents

Advanced age and its related comorbidity may affect both the patterns and goals of diabetes treatment. We examined the relationships of demographic variables and comorbidity with drug treatment for diabetes in the elderly. We studied both the 81,700 residents of New Jersey, aged 65-99 years, who were hospitalized between July 1, 1989 and June 30, 1991 and had prescription drug coverage either through Medicaid or the Pharmacy Assistance for the Aged and Disabled program, and a sample of 80,000 nonhospitalized elderly beneficiaries in these programs. Rates of utilization of insulin or oral hypoglycemic drugs in the 120 days before admission were substantially lower in those aged > or = 85 or in nursing homes. Among patients with previously treated and diagnosed diabetes, the likelihood of treatment after discharge declined with older age (odds ratio [OR] for treatment in those aged > or =85 relative to 65-74 years: 0.57; 95% confidence interval [CI]: 0.45-0.72), nursing home residence (OR: 0.30; CI: 0.22-0.41), and higher levels of comorbidity (OR for modified Charlson index > or = 5 relative to 0: 0.43; CI: 0.27-0.67). In patients who had a discharge diagnosis of diabetes but no prior treatment, those in nursing homes and those with greater comorbidity also had lower rates of diabetes treatment after discharge. Although the prevalence of diabetes increases with age and the risks of many consequences of diabetes remain high, the rate of drug treatment for diabetes declines with older age and greater comorbidity, perhaps because of concern about side effects or reduced treatment benefits due to competing risks of death. Absence of data from randomized clinical trials of diabetes treatment in the elderly appears to have resulted in considerable physician ambivalence on the benefits and risks of glycemic control in older diabetics.