How language barriers impact patient care: a commentary

The population of the United States population is growing more diverse at a rapid rate through the 21st century. Health care providers are interacting more frequently with patients of diverse ethnic affiliations where health beliefs, languages, and life experiences may differ greatly from their own. According to Timmins (2002), "...the U.S. health care system is largely geared toward serving English speakers." This is because language is the most common barrier in any health care setting and has been found to be a risk factor with adverse outcomes. Health care providers and patient communication are positively correlated with improved health outcome. Health outcomes include medication regimen, preventive testing, and patient satisfaction.     

Geriatrics and their meds: problems and perils

The EMS provider often encounters the elderly patient at home, where a comprehensive medication history can be obtained. Because of the aging process, the older patient may not be able to tolerate drug therapy as well as a younger adult. When obtaining a medication history, look and ask for detailed information, including the use of dietary and herbal supplements, especially if the signs and symptoms do not match existing or known conditions. The astute EMT or paramedic may be able to recognize drug-induced illness and alert the emergency department physician. Early intervention may save the elderly patient's life.     

Tetanus and the aged

Tetanus is primarily a disease of the aged. Even though the overall number of cases of tetanus has decreased since 1955, the number of cases of tetanus in people 50 years of age and older has remained constant. The national Center for Disease Control attributes the cases of tetanus in the aged to inadequate immunization levels. Tetanus is preventable and, theoretically, could be eradicated if the population was at an adequate immunization level. There are many reasons why older people are not adequately immunized. These reasons may include the inability to get to a health care facility due to physical disability or lack of transportation, ignorance of the importance of seeking health care for minor injuries, financial constraints and a knowledge deficit on the part of health care providers regarding the immunization needs of the aged. Health care providers can prevent tetanus in the aged through vigilance. All aged clients should be routinely assessed and immunizations updated as necessary. Tetanus will never be eliminated until universal active immunization has been achieved.     

Substance abuse in older adults: policy issues

By 2020, it is projected that the number of older adults needing treatment for drug and alcohol addictions will increase dramatically. Although Medicare covers treatment for mental health issues, copayments can be prohibitive for those with lower incomes. The Positive Aging Act, an amendment to the Public Health Service Act, is a policy alternative that could address substance abuse in the older adult population by (a) demonstrating ways of integrating mental health services for older adults into primary care settings, and (b) supporting the establishment and maintenance of interdisciplinary geriatric mental health outreach teams in community settings where older adults reside or receive social services. Increasing funding to states to emphasize primary care provider education on the detection, evaluation, and treatment of substance abuse problems of older adults has the potential to better meet the substance abuse needs of this population. Educating primary care providers, including gerontological nurses, to recognize signs of substance abuse in this population and providing age-appropriate treatment options is critically important but will require funding beyond what is currently available.     

Dimenhydrinate use for children with vomiting

Question Dimenhydrinate is an over-the-counter drug that is commonly used for the treatment of nausea and vomiting. Many of my adult patients use it, but is it safe and useful in the pediatric population?Answer Dimenhydrinate appears to be safe for use in the pediatric population. While little literature has been published about adverse effects of this medication, family physicians need to identify the cause of the vomiting before considering if the drug will be effective and need to ensure that patients safely use the medication and avoid potential interaction of the drug with other products.     

Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection

OBJECTIVE: To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence. DESIGN: Prospective, direct observation study. SETTING: Tertiary care academic medical center. PATIENTS: Patients in a medical/surgical intensive care unit. INTERVENTIONS: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. MEASUREMENTS AND MAIN RESULTS: The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%). CONCLUSIONS: Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.     

Aminoglycoside dosing in patients by kidney function and area under the curve: the Sawchuk-Zaske dosing method revisited in the era of obesity

Initial dose selection of antimicrobials typically involves the clinical integration of covariates of drug disposition such as age, sex, weight, and kidney function. However, dynamic clinical states and unaccountable confounders necessitate our measurement of systemic concentrations in an individual patient to better inform dose modification. Over the past 50 years, several research groups have formulated weight- and kidney function–based dosing algorithms to measure, assess, and optimize the dosing of aminoglycosides. The lessons learned from older aminoglycosides may be useful and have applications to newer antimicrobials that are dosed on weight and kidney function. This is especially true among obese patients, for whom optimal dosing algorithms have not been well defined. The purpose of this review is to provide healthcare providers a historical perspective of aminoglycoside therapeutic drug monitoring followed by an updated approach to improve dosing of these agents in obese adult patients.     

A year in review: new drugs for older adults in 2011

BackgroundNew drugs approved by the Food and Drug Administration (FDA) may offer tremendous clinical advances by providing health care providers with new treatment strategies. However, additional care must be taken for safe and effective use of these new agents by older adults.ObjectiveOur objective was to identify FDA-approved medications in 2011 most likely to be prescribed to older adults, and to describe medication characteristics that may require special attention in this population.MethodsThe FDA Web site was reviewed for new drug approvals from January through December 2011. Approved labeling for each drug was obtained from the manufacturer's Web site and PubMed was searched for primary literature published between 1967 and 2012.ResultsRivaroxaban, an oral factor Xa inhibitor, is approved for once-daily use in treatment of nonvalvular atrial fibrillation and deep vein thrombosis prophylaxis after replacement of a hip or knee. Drug interactions and renal function must be considered when prescribing this drug to older adults. Fidaxomicin is an oral anti-infective approved for the treatment of Clostridium difficile-associated diarrhea. It has minimal oral absorption or side effects, no relevant drug interactions, but a very high cost. It is a treatment option after failure of oral metronidazole and oral vancomycin. Roflumilast is a selective inhibitor of phosphodiesterase 4 and is approved to reduce the risk of chronic obstructive pulmonary disease (COPD) exacerbations in patients with severe COPD and a history of exacerbations. It is recommended as a second or alternative choice combined with a long-acting bronchodilator in patients at high risk for hospitalization. Indacaterol is an inhaled long-acting β-agonist approved for COPD maintenance. It is administered once daily, which may improve adherence in older adults compared with currently available twice-daily agents.ConclusionsFour new drugs approved in 2011 applicable to the geriatric population are presented. Clinicians must consider the available evidence, cost, drug–drug interactions, renal function, pharmacokinetic/pharmacodynamic differences, and patient preferences when considering prescribing these agents to older adults.     

Nosocomial infections in intensive care patients

Facilities must manage core system processes to minimize medication errors and other adverse outcomes, such as nosocomial infections. Characterization of specific risk factors for the development of nosocomial infections and efficacious evidence-based care interventions are expanding. Health care providers need to evaluate their patient populations and systems of care to minimize lack of knowledge, slips. and lapses in care and other system issues to assure that successful care practices are consistently used to minimize nosocomial infections.     

Management of the social consequences of seizures

People with seizures experience restrictions in many areas of life, including participation in recreational activities, social situations, employment, and driving. Health care providers and patients should be informed of the potential hazards faced by people with seizures. The patient and practitioner who know the potential risks can make rational decisions about participation in these activities. Risk assessment and participation should be individualized according to the patient's unique situation. Understanding the inherent risk of a particular activity, risk of recurrence of seizures, legal restrictions (some activities may be governed by law or specific code), seizure type, and adverse effects of medication may be useful in making decisions concerning participation in a wide variety of activities. The information in this article should be used to maximize the patient's quality of life.     

FDA drug safety communications: a narrative review and clinical considerations for older adults

BackgroundThe US Food and Drug Administration (FDA) has new regulatory authorities intended to enhance drug safety monitoring in the postmarketing period. This has resulted in an increase in communication from the FDA in recent years about the safety profile of certain drugs. It is important to stay abreast of the current literature on drug risks to effectively communicate these risks to patients, other health care providers, and the general public.ObjectiveTo summarize 4 new FDA drug safety communications by describing the evidence supporting the risks and the clinical implications for older adults.MethodsThe FDA Web site was reviewed for new drug safety communications from May 2011 to April 2012 that would be relevant to older adults. Approved labeling for each drug or class was obtained from the manufacturer, and PubMed was searched for primary literature that supported the drug safety concern.ResultsFDA drug safety communications for 4 drugs were chosen because of the potential clinical importance in older adults. A warning for citalopram was made because of potential problems with QT prolongation in patients taking less than 40 mg per day. The evidence suggests minor changes in QT interval. Given the flat dose–response curve in treating depression with citalopram, the new 20-mg/d maximum dose in older adults is sensible. Another warning was made for proton pump inhibitors (PPIs) and an increased risk of Clostridium difficile infection. A dose–response relationship was found for this drug risk. With C. difficile infections on the rise in older adults, along with other safety risks of PPI therapy, PPIs should only be used in older adults indicated for therapy for the shortest duration possible. In addition, a warning about dabigatran was made. There is strong evidence from a large clinical trial, as well as case reports, of increased bleeding risk in older adults taking dabigatran, especially in older adults with decreased renal function. This medication should be used with caution in older adults. Finally, several warnings were made about statins. Routine periodic monitoring of liver enzymes does not appear to be effective in detecting or preventing serious liver injury from statin use; thus, liver enzymes are no longer recommended to be routinely monitored. Statin-induced cognitive changes are rare, and insufficient evidence is currently available to establish causality. Statins appear to moderately increase the risk of developing diabetes (versus placebo), and regular screening for diabetes should be considered, especially for patients taking high-dose statins and patients with multiple risk factors for diabetes.ConclusionFDA drug safety communications incorporate complex methodologies that investigate the risks (and relative benefits) of medication therapy. Clinicians caring for older adults need to be aware of the most current evidence behind these drug risks to effectively communicate with and care for their patients.     

Pharmacotherapeutic options for the treatment of depression in patients with chronic kidney disease.

Depressive disorders occur in up to one-third of patients with chronic kidney disease CKD). First-line pharmacologic treatments include selective serotonin reuptake inhibitors and second generation agents, such as bupropion, mirtazapine, and venlafaxine. Although very little research has been conducted on the use of antidepressants in CKD, health care providers should be aware of renal dose adjustments for these agents, drug interactions, and potential adverse effects. This article reviews the epidemiology and significance of depression in patients with CKD and discusses drug therapy options for treatment of depression in this patient population.     

The impact of reducing dose frequency on health outcomes

BACKGROUND: Dosing schedules may be one important factor determining whether patients take their prescribed medication. Schedules may influence whether a patient stays on the prescribed therapy and, if so, the degree to which the regimen is followed. Both factors are important determinants of health outcomes and health care costs. OBJECTIVE: The goal of this study was to investigate the impact of reducing dose frequency on health outcomes and health care costs. METHODS: Articles from peer-reviewed journals were identified from the medical literature databases MEDLINE, International Pharmaceutical Abstracts, and HealthSTAR for the years 1985 through 2002. The search included all references that reported on the impact of a change of dose frequency on chronic disease. Search terms used were combinations of dose frequency, dose schedule, and dosing and efficacy, safety, clinical effectiveness, preferences, adherence, compliance, persistence, health-related quality of life, patient satisfaction, resource use, and costs. RESULTS: Reducing the number of daily doses through extended-release formulations or newer drugs has frequently been shown to provide the patient with better symptom control in a number of disease states. Overall improvements were seen in adherence, patient quality of life, patient satisfaction, and costs. However, results of some studies indicate that not all patients, medications, or diseases may be candidates for reduced dosing due to the potential effects on symptom control, incidence of adverse events, and overcompensation for missed doses. CONCLUSION: Where feasible, reducing dose frequency may offer benefits for the patient in terms of health outcomes and for the health care budget holder in terms of costs.     

Perspectives on the opioid crisis from pain medicine clinicians

Patients experiencing a terminal drug related event reflect a sentinel event. If this pharmacotherapy is a widely used agent, it may be viewed as a catastrophic problem. If patients are dying from illegal drug use when the medical establishment fails them by withdrawing or minimizing their medically prescribed medication, then the burden rests with their health care providers, legislation, and insurance carriers to actively participate in a collegial fashion to achieve parity. Causing a decay in functionality in previously functional patients, may occur with appropriately prescribed opioid medications addressing non-cancer pain when withdrawing or diminishing either with or without patient consent. The members of the medical profession have diminished their prescribing of opioids for their patients out of apparent fear of reprisal, state or federal government sanctions, and other concerned groups. Diminishing former dosages or deleting the opioid medication, preferably in concert with the patient, often results in inequitable patient care. Enforcing sanctioned decreases or ceasing to prescribe from their former required/established opioid medications precipitate patient discord. In absence of opioid misuse, abuse, diversion or addiction based upon medical “guidelines” and with a poor foundation of Evidence Based Medicine the CDC guidelines, it may be masked as a true guideline reflecting a decrement of clinical judgment, wisdom, and compassion. This article also discusses the role of pharmacy chains, insurance carriers, and their pharmacy benefit managers (PBMs) contribution to this multidimensional problem. There may be a potential solution, identified in this paper, if all the associated political, medical and insurance groups work cohesively to improve patient care. This article and the CDC guidelines are not focused at hospice, palliative, end of life care pain management.     

Clinical pharmacology in the geriatric patient

Geriatric patients are a subset of older people with multiple comorbidities that usually have significant functional implications. Geriatric patients have impaired homeostasis and wide inter-individual variability. Comprehensive geriatric assessment captures the complexity of the problems that characterize frail older patients and can be used to guide management, including prescribing. Prescribing for geriatric patients requires an understanding of the efficacy of the medication in frail older people, assessment of the risk of adverse drug events, discussion of the harm:benefit ratio with the patient, a decision about the dose regime and careful monitoring of the patient's response. This requires evaluation of evidence from clinical trials, application of the evidence to frail older people through an understanding of changes in pharmacokinetics and pharmacodynamics, and attention to medication management issues. Given that most disease occurs in older people, and that older people are the major recipients of drug therapy in the Western world, increased research and a better evidence base is essential to guide clinicians who manage geriatric patients.