How to Get Better Care with Lower Costs? See the Person, Not the Patient

This article discusses the importance of interacting with individuals as “people” not “patients” in order to provide a more all-inclusive type of care. This is especially important for older adults, who experience chronic health problems, functional limitations, physical challenges, and a deeper reliance on social support. Programs such as disease state management fail to recognize a person as a whole, with many other factors affecting their health and outcomes than just one specific disease itself.

The process of a person-centered care program means putting people in charge of their own health. It involves taking time to identify their personal needs, preferences, and values, consulting familial support if needed. When this information is combined with a health and functioning assessment, the person is able to shape their own personal goals rather than those based simply on medically-defined clinical outcomes. This process allows for the development of a care plan and implementation strategy individual for each person. By allowing each person to identify their own personal goals, and providing the needed support for it to happen, they will be much more motivated and successful in striving for those goals. This process has been developed with and supported by the American Geriatrics Society (AGS).

Three critical indicators of quality person-centered care for older adults are high functional quality of life with minimal intervention, healthcare providers acting in an efficient, convenient manner, and ability to easily navigate the care system as needed. The degree or extent of each of these indicators will vary for each person based on individual functional abilities, family support, and more.

There are several models that embrace this paradigm. They have been able to demonstrate that there is an opportunity for better care for high-need older adults at lower costs. These cost savings may not seem favorable initially when considered on a short-term small scale. This is the case with remote mail-order pharmacies for prescription refills rather than direct pharmacy interaction. However, Washington University’s care management program under the CMS Medicare Coordinated Care Demonstration Pilot is working on proving the long-term benefit of face-to-face interaction over mail-order pharmacy experience for individuals in the older adult population. Considering the points made in this article and the person-centered care approach that is outlined, do you think the emphasis we are seeing currently in mail-order pharmacy for many Medicare patients will be short-lived

Westphal, E., Alkema, G., Seidel, R., Chernof, B. How to get better care with lower costs? See the person, not the patient. J Am Geriatr Soc. 2016; 64:19-21. Doi: 10.1111/jgs.13867 

Differences in prescribing psychotropic drugs for elderly with depression.

This study’s purpose was to address the prevalence of depression and inadequacy it is treated in most cases.  It analyzed the different types of drug classes that are prescribed to elderly patients.  A random sampling of 5% of inpatients was selected from the NHI in Taiwan.  Of the 5%, 1058 were geriatric patients with some form of mental depression.  The prescribing patterns were examined and compared.  Some of the most commonly prescribed psychotropics were: antidepressants (71.4%), anxiolytics (62.6%) and hypnotics (51.4%).  Varying types of medications were prescribed and it depends on the the type of medical professional.  This study concluded psychiatrist generally prescribe newer antidepressants than other physician specialties.

This article is interesting because it discussed the varying types of drugs that are prescribed.  It shows that there is a difference between the types of medications prescribed based on the type of specialty instead of having a standard that all prescriptions is based off of.  I believe that this is bad for the healthcare industry and could lead to problems across the industry.

Huang YC, Wang LJ, Chong MY.  Differences in prescribing psychotropic drugs for elderly with depression. Acta NeuroPsychiatry. 2016; 22: 1-8.

Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients

Unfortunately, after elderly patients leave the hospital from an acute hospitalization, most lose the ability to complete some daily living activities, some are readmitted to the hospital, and some die, all within six months. A comprehensive geriatric assessment is completed while the patient is admitted, setting up interventions and taking care of the patient until they are discharged. Transitional care can also be completed when the patient is moving back home after this hospitalization. This care is provided for a limited amount of time, during which nurses attempt to limit the number of adverse drug events, remind patients of discharge information, and follow up with the doctors. A study was completed to measure the effectiveness of patients receiving both comprehensive geriatric assessment services as well as a transitional care program.

Three hospitals from the Netherlands participated in a double-blind randomized clinical trial between September 1, 2010 and March 1, 2014 involving 674 patients 65 or older that were acutely hospitalized for 48 hours or more in the internal medicine department and were at risk for further decline in health. The participants that consented to participating were randomly placed into a group receiving both interventions or purely comprehensive geriatric assessments. Patients receiving transitional care had a nurse visit about four days after they were admitted to the hospital, then two days after discharge and two weeks, six weeks, twelve weeks, and twenty-four weeks after discharge to monitor the patients’ conditions and initiate or follow through with interventions.

It was found that there was no difference in the ability to complete daily living activities between those receiving both treatments and those just receiving comprehensive geriatric assessments. There was a statistical difference however in the ability to complete daily activities between those who died after their acute hospitalization and those who survived for at least six months. 85 participants died among those receiving both treatments and 104 died among those receiving only comprehensive geriatric assessments. There were 106 readmissions among those receiving both interventions and 88 among those receiving only comprehensive geriatric assessments but no time difference was noticed. It was concluded that although there was a lower mortality rate within 1 month and 6 months of discharge in the group receiving both interventions, there was no difference in effect on ability to complete daily living tasks.

Even if this addition of therapy may cause a slight extension of life, is it worth the extra time and cost of nurses to continue providing transitional care when there is no benefit on the patient’s ability to complete everyday tasks?

Reference: Buurman BM, Parlevliet JL, Allore HG, et al. Comprehensive geriatric assessment and transitional care in acutely hospitalized patients: the transitional care bridge randomized clinical trial. Jama Intern Med. Published online February 15, 2016. http://archinte.jamanetwork.com/article.aspx?articleid=2491684

Anticholinergic drugs and health-related quality of life in older adults with dementia

This study was done to see if anticholinergic drugs could be leading to a decreased quality of life among older adults with dementia. There were 112 people involved in the study, most of whom were between the ages of 65 and 79 years old. The results were measured using two separate scores. There was a Physical Component score and a Mental Component score. The results showed a significant decrease in the physical component score, equating to a decreased quality of life. There was no association found between anticholinergic drug use and the mental component score.

Anticholinergic drugs are used to treat a wide variety of medical conditions, many of which are common in older adults, but there are adverse effects with these drugs that could potentially be very dangerous. Anticholinergic drugs can effect mental concentration and increase the risk of falls in older adults. They also cause other adverse effects, such as constipation, urinary retention, and xerostomia, which can lead to a decrease in the patient’s quality of life. Since the drugs were only shown to decrease patient’s physical quality of life and did not improve their mental component score, anticholinergic drugs may not be the best way to treat older patients with dementia.

 

Sneha D. Sura, Ryan M. Carnahan, Hua Chen, Rajender R. Aparasu. Anticholinergic drugs and health-related quality of life in older adults with dementia. Journal of American Pharmacists Association.  2015;55;282-287

http://www.japha.org/article/S1544-3191(15)30061-3/fulltext

Predictive Validity of Beers and STOPP Criteria to Detect Adverse Drug Events in the United States

One of the largest concerns among the geriatric pharmacy community is being able to predict adverse drug events from medications that are inappropriate within the elderly population.  To help with reducing these adverse outcomes and emergency department visits, most geriatric health providers often turn to recommendation resources such as Beers criteria or the Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) for guidance on drugs that are potentially inappropriate medications (PIMs).  The issue with these criteria is a lack of research into how sensitive and accurate they are for predicting ADE or ED visits among the elderly who may have indications for the medications.

A recent study by members of the University of Arkansas, College of Pharmacy published in the Journal of American Geriatrics Society that assessed the predictive power of Beers and STOPP criteria for PIM in elderly populations.  The performed an eight-year retrospective cohort study on over 174,000 commercially insured patients over 65 years old, monitoring them for association between ADE and ED visits based on inappropriate medication use based on the criteria of either 2003 beers, 2012 Beers, or STOPP recommendations.  Over the course of the study, 41% of the patient population were exposed to a PIM from at least one of the criteria sets.  The 2012 Beers criteria identified PIMs in 34.1% of patients and STOPP identified in 27.6% of patients.  Observed differences are related to differences in classification of inappropriateness between the two identification systems.  The two criteria sets showed similar sensitivity and specificity, although they varied in predictive ability between drug classes, given variation in recommendations between classes of drugs for the two systems.

Both systems displayed acceptable prognostic power to predict adverse drug events in patients exposed to PIMs based on their individual criteria.  The study found no significant differences between the two systems in discrimination power for ADEs or ED visits, although the researchers did admit that further studies would be required to increase the predictive power of the criteria sets by medication classes.  This is the first study of its kind to look into the predictive ability of the major geriatric medication recommendations, and needs further assessment by other groups to get an accurate look at the medication lists for the elderly population in the United States.  What should pharmacists and other health care professionals be looking at to determine if our current recommendations are sufficient?  Do you have any ideas to help ensure the current system of geriatric cares are appropriate?

Article Link

Brown, J. D., Hutchison, L. C., Li, C., Painter, J. T. and Martin, B. C. Predictive Validity of the Beers and Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) Criteria to Detect Adverse Drug Events, Hospitalizations, and Emergency Department Visits in the United States. Journal of the American Geriatrics Society (2016) 64: 22–30. doi: 10.1111/jgs.13884

Proton Pump Inhibitors May Increase the Risk of Dementia in the Elderly Population

Proton pump inhibitors (PPIs) are a class of medications that are commonly used in the elderly population to remedy gastrointestinal problems. This prospective cohort study in German  looks at the possible association between these medications and dementia. For the study, the inclusion criteria was at least 75 years old and no diagnosis of dementia. They defined the use of a PPI as having one prescription per quarter of the following medications: omeprazole, pantoprazole, lansoprazole, esomeprazole, or rabeprazole. Patients who only used PPIs occasionally were not included in the study.  This study also worked to analyze other factors that could contribute to the risk of dementia. Some of these factors were gender, the use of multiple prescription medications, stroke, and comorbid diagnosis with conditions such as depression, heart disease, or diabetes. The data analyzed was from 2004 – 2011.

A total of 73,679 people who met the inclusion criteria were analyzed in the study. The results of the study shows that the use of PPIs in the elderly is associated with an increased risk of dementia.  77.9% of patients who took PPIs regularly during this study had a “significantly increased risk of incident dementia”.  The study results also show that males had a higher risk of dementia with use of PPIs. The comorbid diagnosis of depression and stroke had a higher risk of dementia with the use of PPIs. Comorbid diagnosis with diabetes and the use of other prescription medication with PPIs showed a very slight increased risk of dementia. Patients using PPIs with heart disease actually had a slight decreased risk in developing dementia.

This study is important because PPIs are such a commonly used medication class, especially in the elderly population. If these medications are contributing to the onset of dementia, consideration should be given to avoid prescribing this medication in the elderly population. Additionally, this study could eventually lead to a clearer understanding of how disease states such as dementia or Alzheimer’s develop in the first place. From there, we could focus on developing medications that could help to prevent and treat these terrible conditions.

Gomm W, von Holt K, Thomé F, et al. Association of Proton Pump Inhibitors With Risk of Dementia. JAMA Neurol. doi:10.1001/jamaneurol.2015.4791. (Published 15 February 2016).

Monthly High-Dose Vitamin D Treatment for the Prevention of Functional Decline

A major health concern for older populations is increased risk for falls. This is partly caused by reduced lower extremity function, prevention of which could save many injuries from occurring in older adults. Vitamin D has been thought to aid in lower extremity function and is especially believed to help with muscle weakness. To evaluate this, the researchers of this study conducted a double blind clinical trial to evaluate the effects of high-dose vitamin D in older adults. The study looked at 200 men and women with a low-trauma fall in the past year who were also 70 years and older. These 200 participants were separated into three study groups: one receiving 24,000 IU of vitamin D3 per month (normal dose), one receiving 60,000 IU of vitamin D3 per month, and one receiving 24,000 IU of vitamin D3 plus calcifediol per month. At the end of the study, the increase in 25-hydroxyvitamin D levels was evaluated for each group.

The results for the first group receiving 24,000 IU showed that the 25-hydroxyvitamin D levels increased by 11.7 ng/mL after 12 months. The second group receiving 60,000 IU increased its levels by 19.2 ng/mL. Finally, the third group receiving both the 24,000 IU and the calcifediol increased its 25-hydroxyvitamin D levels by 25.8 ng/mL after 12 months. The participants were also tested using the Short Physical Performance Battery (SPPB). This test assessed lower extremity function by evaluating walking speed, balance, and successive chair stands. When looking at the change in SPPB scores, it can be noted that there was no significant difference between the treatment groups. Further data collected from the study also evaluated the incidence of falls in the subjects. During the 12 month period of the study, 121 of the participants fell. The 60,000 IU group and the 24,000 IU group with calcifediol had significantly higher percentages of falls compared with the treatment group that only received the 24,000 IU of vitamin D3.

It was concluded that higher doses of vitamin D monthly do not provide benefit for the decline in lower extremity function. This was shown through the SPPB scores and the lack of improvement with higher doses. Also, high doses were shown to increase the number of falls in participants and, therefore, may be considered unsafe in older adults who have already experienced a fall.

I found this study to be interesting because we are often told how over the counter vitamins and herbals do not have much research behind them. I therefore chose to read this article to learn more information about vitamins. The study actually proved to me how little we seem to know about these supplements. The consensus on vitamin D that was used as the basis for this study was that it can improve muscle function. However, high doses of it actually seem to have done more harm than good. As a pharmacist, it is important to know this information when evaluating the medication regimen of an older adult. Doses of vitamin D should be monitored closely with someone who experiences falls, especially if they are taking other medications that may also contribute to more frequent falls.

Citation:

Bischoff-Ferrari H, Dawson-Hughes B, Orav J, et al. Monthly high-dose vitamin D treatment for the prevention of functional decline: a randomized clinical trial. JAMA Intern Med. 2016; 176(2): 175-183.

http://archinte.jamanetwork.com/article.aspx?articleid=2478897

Benzodiazepine use and risk of incident dementia or cognitive decline: prospective population based study

A study investigated the use of benzodiazepines the risk of it causing dementia or rapid cognitive decline. Benzodiazepines are used among 9-12% of older adults in the United States to treat anxiety and insomnia. Drugs that fall into this class are not recommended for long term use in older adults due to the associated increased risk of falls and delirium. Single dose studies found that benzodiazepines impair memory and attention span, but its effect in long term use is still uncertain. One problem with determining if long term benzodiazepine use increases the risk of dementia is that dementia is often preceded by anxiety and insomnia: symptoms often treated with benzodiazepines. Two out of three known studies that considered early dementia symptoms and potential for reverse causation reported an increased risk of dementia with benzodiazepine use.

The investigators hypothesized that cumulative, heavier benzodiazepine exposure over a long period of time was the most likely mechanism to cause an increased risk of dementia. The study was conducted within an integrated healthcare delivery system in the North West US. There were 3434 randomly selected participants in the study aged 65 or older who did not have dementia at the start of the study. Every two years, the cognitive abilities screening instrument (CASI) was administered to test for dementia. It was also used to assess cognitive trajectory. Computerized pharmacy data was use to define benzodiazepine exposure associated with risk of dementia. This consisted of the total standardized daily doses (TSDDs) over a 10 year period. The date of onset dementia was made the midpoint between the visit triggering the dementia evaluation and the visit before that.

While the study found a slightly higher risk of dementia associated with the lowest use of benzodiazepine, it did not find an increased risk in those using the highest level. Therefore, the findings do not support the theory that cumulative use of benzodiazepines at levels used in our population has a causal relationship to increased risk of cognitive decline or dementia. However, the study did not investigate acute adverse cognitive effects that can occur upon starting benzodiazepine treatment in older adults. Healthcare providers should still avoid benzodiazepine use in older adults to prevent other important adverse effects. Considering that other studies did report a causal relationship, it seems that this is a topic that still requires more investigation.

Gray GL, Dublin S, Yu O, et al. Benzodiazepine use and risk of incident dementia or cognitive decline: prospective population based study. BMJ. 2016;352:90.