Ashley Harrison UGA Doctor of Pharmacy Candidate Class of 2012 Journal Club June 2011

1. Year in Review: Medication Mishaps in the ElderlyPeron P, Marcum Z, Boyce R, Hanlon J, Handler S, et al. The American Journal of Geriatric Pharmacotherapy. 2011 Feb; 1-10. Ashley Harrison UGA Doctor of Pharmacy Candidate Class of 2012 Journal Club June 2011

2. Level of Evidence: IB

3. Objective To review articles from the 2010 calendar year regarding medication errors or adverse events in the elderly population

4. Design: Inclusion Criteria • A MEDLINE and EMBASE search was performed to find studies involving the following terms: • Medication errors • Adherence • Compliance • Suboptimal prescribing • Monitoring, adverse events • Adverse withdrawal events • Therapeutic failures • Aged

5. Design • 5 studies were chosen to be reviewed: • Potential under-prescribing • Changes In Under-treatment After Comprehensive Geriatric Assessment: An Observational Study • Inappropriate prescribing • Preventing Potentially Inappropriate Medication Use In Hospitalized Older Patients With A Computerized Provider Order Entry Warning System • Medication adherence • Adverse Effects Of Complementary And Alternative Medicine On Antihypertensive Medication Adherence: Findings From The Cohort Study Of Medication Adherence Among Older Adults • Medication-related adverse events • Risk For Fractures With Centrally Acting Muscle Relaxants: An Analysis Of A National Medicare Advantage Claims Database • Identifying And Preventing Adverse Drug Events In Elderly Hospitalized Patients: A Randomized Trial Of A Program To Reduce Adverse Drug Effects

6. Potential Underprescribing Changes In Under-treatment After Comprehensive Geriatric Assessment: An Observational Study

7. Summary • Elderly patients were enrolled to assess the impact of comprehensive geriatric assessment on the prevalence of undertreatment in this population • “Undertreated”- lacking drugs indicated for 1 of 10 commonly undertreated diseases • Before CGA: 32.9% were considered undertreated • After CGA: 22.3% were considered undertreated (P <0.01) • These rates are even higher in the U.S. (50-65% undertreated)

8. Conclusion CGA reduces suboptimal prescribing in the aged population

9. Potential Inappropriate Prescribing Preventing Potentially Inappropriate Medication Use In Hospitalized Older Patients With A Computerized Provider Order Entry Warning System

10. Summary • Computerized Provider Order Entry (CPOE) system with clinical decision support (CDS) was implemented to assess its effect on orders for potentially inappropriate medications in elderly patients • Before CPOE: average rate of 11.56% PIMs ordered per day • After CPOE: 9.94% (P <0.001) • There were no changes in the rate of medication orders not targeted by the system

11. Conclusion Specific CDS alerts within a CPOE system used in patients > 65 y/o decreased the number of orders for potentially inappropriate medications

12. Medication Adherence Adverse Effects Of Complementary And Alternative Medicine On Antihypertensive Medication Adherence: Findings From The Cohort Study Of Medication Adherence Among Older Adults

13. Summary • The use of CAM was compared with adherence to antihypertensive medications in the elderly population using the Morisky Medication Adherence Scale (MMAS-8) • How often do you forget to take your high blood pressure medication? • How often did you miss taking your high blood pressure medication in the past 2 weeks? • Have you ever cut back on taking your high blood pressure medication because you felt worse? • Do you forget to bring medication when leaving home? • Did you take your high blood pressure medication yesterday? • Do you stop taking medications because problem is under control? • Have you ever had difficulty sticking to a treatment plan? • How often do you have difficulty remembering to take your high blood pressure medication? *Low adherence: Score <6 *Not low adherence: Score >6

14. Results • 14.1% of patients self-reported being non-adherent (MMAS score <6) • 26.5% used CAM to manage their hypertension • Results varied upon race: • 30.5 blacks vs. 24.7% of whites reported CAM use (P<0.005) • 18.4% of blacks vs. 12.3% of whites had low antihypertensive medication adherence (P<0.001) • The risk of CAM use affecting medication adherence was higher in blacks than in whites

15. Conclusions • CAM use is more common in older African American patients • CAM use may have a negative impact on antihypertensive medication adherence • It is essential to question patients about the use of non-prescription medications, since many do not self-report CAM use

16. Medication-Related Adverse Patient Events Risk For Fractures With Centrally Acting Muscle Relaxants: An Analysis Of A National Medicare Advantage Claims Database

17. Summary • The risk of facture injury was assessed for patients > 65 y/o who were prescribed skeletal muscle relaxants • Patients in the experimental group had at least 1 ICD-9 code for fracture and at least 1 prescription within 3 months before the fracture event • Patients taking muscle relaxants had increased risk of fracture (OR 1.4, 95% CI) • The use of > 2 muscle relaxants did not significantly increase the risk of fracture compared to a muscle relaxant used alone • Long-acting and short-acting benzodiazepines also increased the risk, especially when combined with a muscle relaxant (OR 2.66, 1.86 respectively, 95% CI)

18. Conclusions • Skeletal muscle relaxants are associated with falls and fractures and should therefore be placed on the Beers list as PIMs • When > 2 drugs acting on the CNS are used in combination, the risk for fracture is increased.

19. Medication-Related Adverse Patient Events Identifying And Preventing Adverse Drug Events In Elderly Hospitalized Patients: A Randomized Trial Of A Program To Reduce Adverse Drug Effects

20. Summary • Experimental group’s healthcare team received 1 week of educational intervention regarding geriatric pharmacotherapy topics • There was a 2 week follow-up period in both the experimental and control groups in which ADEs were recorded. These were evaluated by a team of healthcare professionals • Control group: 26.1% ADEs reported • Intervention group: 19.4% ADEs reported • Overall, 28% of the ADEs were found to be preventable

21. Conclusion • Implementing education intervention in healthcare teams decreased the number of adverse drug events reported in hospitalized patients in France

22. Author’s Conclusions The data found in these studies is instrumental in helping healthcare professionals understand medication errors and adverse drug events, as well as how to prevent them This information may also help to guide further research and clinical practices in the future

23. My Conclusions The risk of medication errors and mishaps is particularly high in the elderly population due to polypharmacy and decline in the function of multiple body systems. Any preventative measures that can be taken to ensure the safety of these patients and decrease the number of medication errors is beneficial and should be implemented.