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Medications
Pages 53-64

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From page 53...
... Far more challenging is the definition and quantification of more relevant kinds of drug-induced morbidity, including falls and fractures, mental status changes, or, at the extreme end of the continuum, the broad category of functional, cognitive, and affective states that together are known as quality of life outcomes. Defining the disability-preventing actions of medications is equally difficult, which may tend to deter the consideration of these aspects.
From page 54...
... There is a well-documented decrease in renal function with advancing age, which increases the effect of medications (e.g., digoxin, cimetidine, aminoglycosides) that are excreted primarily through the kidney.39 Although there is a clear age-related decline on average as people age, more recent research has made it clear that there is great interindividual variability in the pace with which such declines occur.28 This finding has important implications for the effect of medications on individual elderly patients: the older the patient, the less able the physician will be to predict the optimal dose of a medication on the basis of clinical judgment and routine laboratory tests alone.
From page 55...
... Are drug-induced illnesses more common in the elderly because they are inevitable consequences of the use of powerful therapeutic agents in an age group that needs them, or could more judicious use of therapies result in a reduction in the rates of adverse drug reactions? The latter possibility is addressed in a study of several hundred emergency admissions to a teaching hospital, in which preadmission outpatient records were reviewed to determine whether the admission could have been prevented.
From page 56...
... It is only in the last few years that clinical trials specifically designed to address high blood pressure in the elderly have begun to appear.2 Data from these studies indicate that it is, indeed, advantageous to treat high blood pressure in older patients, at least up to age 80, and that, applied widely, this practice could prevent considerable morbidity, especially from stroke. These findings, however, have not yet begun to permeate the consciousness of many practicing physicians See Chapter 3 for a more detailed discussion of high blood pressure)
From page 57...
... In addition to the methodological challenge of quantifying the relative benefit of prolonging life in older versus younger patients, there is also the thorny issue of quantifying the "good" derived from postponing or preventing cardiovascular disability in the two age groups. These difficulties are by no means unique to the evaluation of drug therapies and apply with equal vexation to such interventions as smoking cessation and dietary change.
From page 58...
... Within this framework, medications that initially appear to have comparable therapeutic efficacy in terms of a narrowly defined outcome may have vastly different effects on more broadly defined measures of health status. Specifically, antihypertensive therapies have different effects on cognition and mood, independent of their impact on blood pressure.
From page 59...
... Physicians are not as proficient as they might be in optimal prescribing for the elderly, a deficit reflected in actual prescribing practices, 33 and in surveys of physician knowledge.4 20 In addition, physician-patient communication is often problematic, both in the areas of history taking for therapeutic decision making and communication about drug effects, precautions, and compliance.~7 i9 Fortunately, a number of interventions have been developed to address these problems; some have even been field-tested in randomized controlled trials. Traditional educational methods using group lectures and mailed informational material appear to be of limited efficacy in changing prescribing practices;7 24 44 however, consistent, reproducible data indicate that in-person, face-to-face education provided by cTinical educators [either pharmacists or other physicians)
From page 60...
... resulted in a significant reduction in the excessive use of psychoactive medication in the six long-term care facilities stuclied.5 The intervention, which consisted of separate educational sessions with physicians, nurses, and aides, also resulted in an improvement in the cognitive status of residents in the experimental homes as measured by a detailed battery of neuropsychiatric and functional status tests. RECOMMENDATIONS Services 1.
From page 61...
... for a patient who needs it.3i,36 In the coming decades, the increasing role of government and other payers in shaping clinical decision making will make it more acceptable to require demonstrations of competence in various areas of practice, including prescribing for the elderly, to maintain credentials or receive payment for services.10 4. Several groups have demonstrated that educational outreach by medical schools ("public interest detailing")
From page 62...
... 5. The use of existing, claims-based data sets of prescription information to study drug effects in the elderly should be increased.~3 35 With such data sets, drug epidemiologists can provide surveillance to track adverse drug effects in key subpopulations.
From page 63...
... Hospital admissions due to drug reactions: A comparative study from Jerusalem and Berlin. Eurocean Journal of Clinical Pharmacology 1980; 17:25.
From page 64...
... F., and Schaffner, W A study of antipsychotic drug use in nursing homes: Epidemiologic evidence suggesting misuse.


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