Polypharmacy and falls in older people: Balancing evidence-based medicine against falls risk

The term polypharmacy has negative connotations due to its association with adverse drug reactions and falls. This spectrum of adverse events widens when polypharmacy occurs among the already vulnerable geriatric population. To date, there is no consensus definition of polypharmacy, and diverse definitions have been used by various researchers, the most common being the consumption of multiple number of medications. Taking multiple medications is considered a risk factor for falls through the adverse effects of drug–drug or drug–disease interactions. Falls studies have determined that taking ≥ 4 drugs is associated with an increased incidence of falls, recurrent falls, and injurious falls. In light of existing evidence, careful and regular medication reviews are advised to reduce the effect of polypharmacy on falls. However, intervention studies on medication reviews and their effectiveness on falls reduction have been scarce. This article reviews and discusses the evidence behind polypharmacy and its association with falls among older individuals, and highlights important areas for future research.     

Probable drug-drug interaction leading to serotonin syndrome in a patient treated with concomitant buspirone and linezolid in the setting of therapeutic hypothermia

What is known and objective: Serotonin syndrome can be a rare but life‐threatening condition that is commonly the result of a drug–drug interaction causing excessive serotonin activity. The symptoms associated with serotonin syndrome can include hyperthermia, mental status changes, autonomic hyperactivity and neuromuscular abnormalities, all of which can be concealed in the critically ill patient owing to concomitant therapies. The objective of this case report is to describe a probable drug–drug interaction between buspirone and linezolid, and to highlight the potential confounding effects of hypothermia in this case. Case summary: We present a case of a 28‐year‐old man who potentially developed serotonin syndrome after coadministration of buspirone and linezolid while being therapeutically cooled for traumatic brain injury. The patient developed hyperthermia, hypertension and tachycardia when buspirone and linezolid were administered concomitantly for 2 days. Symptoms resolved within 24 h after discontinuation of both medications. What is new and conclusions: Caution should be used in patients receiving multiple serotonergic agents in addition to therapeutic hypothermia. The use of therapeutic hypothermia may mask the symptoms associated with serotonin syndrome, thus delaying the diagnosis and treatment of this potentially deadly condition. If a patient requires the combination of such medications, close monitoring for the symptoms of serotonin syndrome is warranted.     

Adverse drug reactions and drug interactions as causes of hospital admission in oncology

Context

Although several studies have evaluated the frequency of adverse drug reactions (ADRs) and drug-drug interactions (DDIs) in general medicine, few studies have looked at the epidemiology of adverse drug events (ADEs) in oncology.

Objectives

We sought to investigate how many hospital admissions in oncology are related to a DDI or an ADR.

Methods

All cancer patients admitted to an oncology ward during an eight-month period had their charts retrospectively evaluated for reasons of hospitalization, using a 4-point scale (definitely, probably, possibly, or unlikely associated) to classify admissions by their probability of being associated with either a DDI or an ADR.

Results

From September 2007 to May 2008, there were 550 hospital admissions and 458 were eligible. Among unplanned admissions (n = 298), 39 (13.0%, 95% confidence interval [CI] 9.4%–17.4%) were considered to be associated with an ADE, 33 (11.0%, 95% CI 7.7%–15.2%) with an ADR, and six (2.0%, 95% CI 0.7%–4.3%) with a DDI. The most common DDIs involved warfarin, captopril, and anti-inflammatory agents, and the most frequent ADR was neutropenic fever post-chemotherapy. Most patients were discharged completely recovered, but two patients died.

Conclusion

Approximately one in 10 unplanned hospitalizations of cancer patients is associated with an ADE. Prospective and population-based studies are warranted to evaluate their magnitude in oncology.     

Prescribing for older people in nursing homes: strategies to improve prescribing and medicines use in nursing homes

Interventions to improve prescribing in the nursing home environment are many and varied. The critical literature review presented in Paper 1 (Parsons et al., 2011, International Journal of Older People Nursing 6, 45-54) in this series discussed the main issues repeatedly identified as problematic, and this paper summarises the main approaches which have been used to attempt to improve prescribing. These include national legislation which demands documented justification for the prescribing of medicines, medication review, approaches to reducing medication errors, improving communication across care boundaries and assessment teams and alternative service models. It is difficult to make global recommendations as some of these approaches are country specific or have been delivered in different ways, involving different professionals. However, a series of prompt questions have been provided which may assist nursing home staff in deciding whether prescribing is optimal in a resident or if an intervention is required which may lead to an overall improvement in outcomes.     

Medication management and older patients: an individualized and systematic approach

? The aim of this action research study was to evaluate the effectiveness of an individualized education programme on older patients’ knowledge of prescribed medication. ? A questionnaire for assessment of medication knowledge was used to collect data from 15 patients at two intervals, before and after an individualized education programme. Following the collection of pre‐intervention data, an individualized education programme was developed for each patient. As part of the education programme patients also had an opportunity to self‐administer their medication. ? The results of the study showed that all participants scored higher in the post‐test than the pre‐test although the degree of improvement varied between participants. Patient satisfaction with the education programme was also assessed and revealed a high level of satisfaction. ? The most significant finding was the importance of tailoring education programmes to meet the needs of the older person. This is borne out by case studies, which suggest that the most relevant characteristic of successful participants is a real desire to remain independent and in control of their medication. ? The findings question the value of standardized programmes of medication education that treat older people as a homogeneous population. The article concludes by emphasizing the need for nurses and other healthcare professionals to individualize their teaching and learning strategies to meet the needs of older patients.     

Multifactorial approach and adherence to prescribed oral medications in patients with type 2 diabetes

The aims of this study were to assess adherence to oral hypoglycaemic/cardiovascular drugs and determine non-adherence predictors in type 2 diabetes patients. It was designed as a population-based cross-sectional study in which 90 patients from a primary care setting were studied. Pill count and self-report methods were used to measure adherence. Logistic regression analysis was performed to predict factors related to non-adherence. Adequate adherence to all drugs was found in 29 patients (35.4%; 95% confidence interval (CI) 25.0-45.7). Variables associated with non-adherence were HbA1c odds ratio (OR) 2.32 (95% CI: 1.09-4.95), systolic blood pressure OR 1.68 (95% CI: 1.08-2.62), total cholesterol OR 1.34 (95% CI: 1.08-1.66), number of pills OR 1.80 (95% CI: 1.26-2.55) and duration of disease OR 0.44 (CI 95%: 0.24-0.83). In conclusion, one in three patients had adequate adherence. Factors associated with non-adherence were duration of disease, complexity of drug regimen and inadequate control of cardiovascular risk factors.     

Trends and challenges in the management of tracheostomy in older people: the need for a multidisciplinary team approach

The trend towards increasing representation of older people as recipients of health care in acute care settings is matched with a corresponding increase in the numbers of older people undergoing tracheostomy.The reasons for tracheostomy in this age group are varied, including respiratory failure, neurological injury/event and carcinomas. Further, current research supports early tracheostomy for patients requiring medium to long-term ventilation and unconscious patients at risk of airway obstruction. In spite of this increase very little has been written about decision making and ongoing nursing care for these patients.There is an abundance of literature on the physiological processes of aging and the problems related to comorbidities; however, there has been very little exploration of how these impact on the occurrence of complications and other outcomes for older patients with a tracheostomy, and the consequent implications for care provision. This article examines clinical issues of significance to older people with tracheostomy and outlines the implementation and benefits of a multidisciplinary team approach.     

Factors associated with use of falls risk–increasing drugs among patients of a geriatric oncology outpatient clinic in Australia: a cross‐sectional study

Older people with cancer are at increased risk of falling. Falls risk–increasing drugs (FRIDs), comprising psychotropics and medications that cause orthostatic hypotension, are a potentially modifiable risk factor for falls. The objective of this study was to determine the prevalence and factors associated with use of FRIDs in older people with cancer. Patients aged ≥70 years who presented to a hospital outpatient clinic between January 2009 and July 2010 were included in the study. Information on current medication use, falls in previous 6 months, and frailty criteria was collected. Multinomial logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (CIs) for factors associated with levels of FRID use. Overall, 76.1% (n = 293) of 383 patients used FRIDs. This comprised psychotropics (31.2%, n = 120) and medications causing orthostatic hypotension (69.9%, n = 269). In total, 24.0% (n = 92) patients reported falling in the previous 6 months. Risk factors for falling were associated with use of psychotropics but not orthostatic hypotension drugs. Patients with a history of falls had increased odds of using psychotropics (≥3 psychotropics; OR 13.50; 95%CI, 2.64‐68.94). Likewise, frail patients had increased odds of using psychotropics (≥3 psychotropics; OR 27.78; 95%CI, 6.06‐127.42). Risk factors for falling were associated with the use of psychotropics. This suggests that clinicians either do not recognize or underestimate the contribution of medications to falls in this high‐risk patient group. Further efforts are needed to rationalize medication regimens at the time of patients' first presentation to outpatient oncology services.     

Allowing and assisting patients to die: the perspectives of oncology practitioners

The moral distinctions between prolonging life, allowing for a dignified death, and assisting patients to die (hastening death) are troublesome to health practitioners. On 26 June 1997 the United States Supreme Court ruled that individuals do not have a constitutional right to physician-assisted suicide, but that individual states can legislate their preferences. Given this ruling it becomes important to ascertain the opinions of practitioners caring for persons who are at the end of their life. The data from interviews with 11 nurses and 10 physicians, who practice in the field of oncology, revealed issues associated with the care of dying persons. How health professionals integrated their perspectives of science/data with their perspectives on persons and personal goals affected the vigour with which they would institute treatment for the terminal patient. Further, ethical uncertainty dominated the decision making of all participants in this study when they were confronted with the question of assisting/hastening patients' dying.     

建立糖尿病管理中心对社区糖尿病病人实施综合干预

目的:探讨社区糖尿病病人有序和科学的管理方式,更好地普及糖尿病的防治知识,提高社区糖尿病病人的生活质量。方法:建立糖尿病管理中心,采用多种形式对所在辖区糖尿病病人实施综合干预,干预前后对病人进行糖尿病相关知识的测评,同时测量干预前后病人的生化指标。结果:经过护理干预后,社区糖尿病病人对相关知识的了解、各项生化指标、知识掌握率、行为改变、技能合格率指标优于干预前,分别经χ2检验,差异有统计学意义(P<0.01)。结论:通过建立糖尿病管理中心对社区糖尿病病人实施综合干预,推进糖尿病社区教育工作发展,提高病人对糖尿病相关知识的了解,有效控制糖尿病病人血糖及并发症发生,提高其生活质量,提高全民族健康水平。