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background: Cholinesterase (ChE) inhibitors enhance central cholinergic function and are considered as standard treatments to ameliorate symptoms relating to Alzheimer's disease. Though anticholinergic medications directly antagonize the effects of ChE inhibitors, they are commonly prescribed among hospitalized adults. objective: To determine the impact of high anticholinergic burden (ACB) on length of stay (LOS) and 30-day readmission rates among hospitalized patients receiving concomitant ChE inhibitors. methods: This was a retrospective cohort study conducted at a tertiary care academic medical center involving hospitalized patients on medical floors who received any Food and Drug Administration-approved ChE inhibitors during their hospital stay from October 1, 2022, to September 30, 2023. The primary outcome of the study was to compare hospital LOS among patients with high (ACB≥ 3) versus low (ACB < 3) ACB. The secondary outcome was to assess the impact of ACB burden on 30-day readmission rates. results: Among hospitalized adults, patients with high ACB exposure had a significantly longer hospital LOS (median: 5.50 vs 4.25 days; P < 0.001) than patients with low ACB exposure, after adjusting for covariates. Analysis of secondary outcome revealed that though the high ACB group had a higher 30-day readmission rate compared with the lower ACB group (6.8% vs. 2.2%), the difference was not statistically significant (OR = 3.46, 95% CI 0.85-14.08; P = 0.083). conclusion: A high ACB exposure among older individuals taking concurrent ChE inhibitors is associated with a longer hospital stay. [ABSTRACT FROM AUTHOR]

BACKGROUND: In older inpatients, anticholinergic medications can increase the risk of complications that may increase length of stay (LOS). Cyclobenzaprine is an anticholinergic medication associated with mental status changes, falls, and injuries in older patients. OBJECTIVE: The purpose of this study is to determine whether use of a lower cyclobenzaprine dose (5 mg) compared with higher dosing (10 mg) will affect LOS, 30-day readmission rates, and need for injectable psychotropic agents in inpatients 65 years of age and older. METHODS: This was a retrospective cohort analysis comparing outcomes in patients 65 years of age and older who received either a 5 mg or 10 mg cyclobenzaprine dose during their inpatient admission over a 2.5-year period. The primary outcome was hospital LOS, adjusted using multivariate linear regression. Secondary outcomes included 30-day readmission rate adjusted using logistic regression and use of injectable antipsychotics or benzodiazepines. A sub-analysis evaluated the impact of the institution’s implementation of a geriatric prescribing context (GEM-CON) on cyclobenzaprine dose selection. RESULTS: The adjusted LOS was 32.7% longer (95% CI 25.9%-39.9%) for patients exposed to higher-dose cyclobenzaprine. Use of injectable antipsychotics or benzodiazepines was also significantly greater in the higher-dose group (P < 0.001; P = 0.025). Cyclobenzaprine dose was not significantly associated with readmission on multivariate analysis (OR = 0.93, 95% CI 0.45-1.93). After GEM-CON implementation, there was a significant increase in use of the recommended lower cyclobenzaprine dose (P < 0.001). CONCLUSION: Use of lower cyclobenzaprine dosing in older inpatients is associated with reduced hospital LOS and need for injectable antipsychotics and benzodiazepines. [ABSTRACT FROM AUTHOR]

Parkinson's disease (PD) is a debilitating condition that affects 1.8% of people 65 years of age and older. Patients with PD often require hospitalization and are frequently admitted through the emergency department (ED). Notably, their hospital durations tend to be lengthier compared with patients without PD. The primary outcome of this research was to compare the length of stay (LOS) of patients who received carbidopa-levodopa (CL) in the ED with those who did not. Secondary outcomes included 30-day-readmission rates and administration of injectable for agitation. In addition, the percentage of patients receiving CL before and after an information management technology (IMT) alert implementation was compared in a sub-analysis. Patients that received CL during their inpatient stay were identified by a database report in this retrospective study. Patients were excluded if they were not admitted through the ED, younger than 65 years of age, or admitted to the intensive care unit after the ED. There was a total of 266 in the control group and 217 patients in the intervention group. The intervention group had a significantly shorter LOS than the control group (3.29 vs 5.37 days; P = 0.002), significantly less frequent 30-day readmissions (P = 0.032), and used fewer injectables for agitation (P = 0.035). The sub-analysis of the IMT alert revealed that prior to the alert's implementation, 28.5% of patients received CL in the ED; whereas post-alert, this percentage increased to 91.4% (P < 0.001). The results of this study found that the group of PD patients who received CL in the ED had shorter LOS, lower 30-day readmissions, and used less injectables for agitation compared with the group that did not receive CL in the ED. This improvement is possibly due to continuity of CL supply considering its short half-life and clinical importance for PD. [ABSTRACT FROM AUTHOR]

BACKGROUND: Currently, our institution does not have a full-time pharmacist rounding with the inpatient acute care of the elderly (ACE) team daily. We sought to evaluate the involvement of a clinical pharmacy service within the ACE team and its impact on appropriate medication use. OBJECTIVE: The primary outcome was the number of drug-related problems (DRPs) and potentially inappropriate medications (PIMs) detected by the pharmacist compared with no pharmacist on the ACE team. Secondary outcomes included length of stay, 30-day re-hospitalization, and accepted DRPs and PIMs recommendations made by the pharmacist. METHODS: This was a retrospective, single-center, cohort study. The control cohort consisted of patients seen over 3 months when no pharmacist was present. The intervention cohort comprised patients seen over 3 months when a pharmacist was present on the ACE team. Patients were excluded if there was not a documented chart note from a geriatric provider or pharmacist. RESULTS: A total of 125 patients were included in the intervention group and 106 patients in the control group. Regarding the primary outcome, the control cohort had significantly fewer identified PIMs and DRPs in comparison with the intervention cohort (P < 0.001; P < 0.01, respectively). There was no significant difference in length of stay (P = 0.317). There was a statistical difference between groups regarding 30-day readmission rates (P = 0.007). CONCLUSION: Our study shows that the inclusion of a pharmacist on the ACE team was associated with more DRPs, and PIMs identified, creating a positive impact on patient care and 30-day readmission. [ABSTRACT FROM AUTHOR]

Background: Haloperidol can be used off-label for agitation and/or delirium in older individuals. The recommended initial intramuscular or intravenous dose is 0.5 to 1 mg. However, the evidence to support these doses is nominal. Objectives: The primary outcome was to determine whether low-dose injectable haloperidol (≤0.5 mg) was similar in effect to higher doses by assessing the need for repeat doses within 4 hours as a surrogate marker. Secondary outcomes include comparison of length of stay, utilization of restraints, and discharge outcomes between dosage groups. Methods: This was a retrospective, single-center, cohort study. Patients aged ≥65 years who received haloperidol injectable who were not on antipsychotics prior to admission were reviewed. Results: In the low-dose group (n = 15), no patients required additional haloperidol doses within 4 hours compared with 1 patient each in the medium-dose (n = 23) and high-dose (n = 19) groups (P = 0.94). There was a difference regarding length of stay, utilization of restraints, and discharge to facility when admitted from home favoring low-dose haloperidol. Conclusions and Relevance: While limited by sample size and retrospective design, patients who received low-dose haloperidol demonstrated similar efficacy to those who received higher doses of haloperidol. In addition, secondary outcomes mentioned above favored the use of low-dose haloperidol as well. Based on these findings, low-dose haloperidol is a reasonable initial dose for the agitated older patient. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine if a pharmacist driven Geriatric Medication Safety Initiative (GEMSI) procedure decreased the utilization of opioids during the residents stay in the Transitional Care Unit (TCU). METHODS: This single-center, retrospective, cohort chart review study will be conducted at a Community Hospital TCU. The study has been approved by our Institutional Review Board (Review# 2176891-1). Residents will be included if admitted to TCU in either 2016 or 2018. Residents will be excluded if it was necessary to transfer off TCU during their TCU stay. The primary endpoint will be to examine Milligram Morphine Equivalent (MME) pre- and post-implementation of GEMSI. The secondary endpoints will include milligrams and doses of acetaminophen utilized, numbers of lidocaine patches utilized, and resident reports of pain management. Statistical analysis will be performed using SPSS IBM Version 29. Categorical data will be presented in count and percentages, while continuous data will be presented in mean and interquartile range. To identify any differences between the pre and post GEMSI groups, Chi-square and Mann Whitney U test analysis will be utilized for categorical and continuous variables, respectively. CONCLUSION: The results will describe the change in opioid utilization (if any) and other variables mentioned after implementation of GEMSI procedure during the residents TCU stay. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether a deprescribing effort reduced several key classes of medications, and the overall number of medication classes per patient, among long-term residents of skilled nursing facilities (SNFs). DESIGN: Retrospective, longitudinal pre/post evaluation. Data from before and during the implementation of the deprescribing effort (2017 through 2019) were compared with data from the post-intervention year (2020). SETTING AND PATIENTS: Long-term resident data reported through annual comprehensive reviews conducted at two SNFs located in central New York State between 2017 and 2020 (N = 12,144). INTERVENTIONS: Multifaceted, interdisciplinary deprescribing effort to reduce medications in SNF residence including clinician education, guideline development, and individual chart reviews began in 2019. RESULTS: The mean number of medications prescribed per resident was lower at both facilities after the intervention (mean = 1.74 at both facilities) versus preintervention (1.90 at Facility 1, 1.86 at Facility 2). Significant decreases were observed in the usage rates for diuretics (-4.2%; P = 0.001), opioids (-3.8%; P = 0.001), and antipsychotics (-2.4%; P = 0.010). The raw antidepressant usage rate increased by 1.5% after the intervention but the change was not significant. Effects were robust to covariate adjustment. CONCLUSION: A combined, comprehensive approach to deprescribing was associated with a reduction in the overall number of medication classes per resident and in several key classes of medications. Additional research with more data and covariate control is in progress for verification of these findings. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To review the data informing the US Food and Drug Administration (FDA) approval for aducanumab for mild cognitive impairment (MCI) and mild Alzheimer’s disease (AD). DATA SOURCES: At the time of writing there were no peer-reviewed published studies on aducanumab. All data presented are derived directly from the material Biogen submitted to the FDA for approval. The three studies that will be reviewed are: Multiple Dose Study of Aducanumab in Participants With Prodromal or Mild AD (PRIME), 221AD302 Phase 3 Study of Aducanumab in Early AD (EMERGE), 221AD301 Phase 3 Study of Aducanumab in Early AD (ENGAGE). DATA SYNTHESIS: PRIME, which was a phase 1 study, demonstrated the most common adverse drug reactions were amyloid-related imaging abnormalities (ARIA), which occurred at rates up to 47% (10 mg/kg group), headache (25%), urinary tract infection (16%), and upper respiratory tract infection (19%). EMERGE demonstrated that high-dose aducanumab was clinically significant at slowing down clinical decline. However, ENGAGE was terminated early based on a futility analysis. Prior to termination ENGAGE demonstrated no clinical difference between treatment and placebo regarding the primary endpoint of slowing clinical decline. CONCLUSION: Based on the data to date, it is difficult to accurately assess the role of aducanumab in patients with MCI or mild AD. EMERGE showed benefit with high-dose aducanumab slowing clinical decline. However, ENGAGE did not duplicate this benefit. With conflicting evidence of positive outcomes, future phase III studies are needed to confirm efficacy. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Evaluate the impact of a telepharmacy service at a geriatrics assessment clinic. DESIGN: Retrospective, single-center, nonblinded cohort study. SETTING: Geriatrics assessment clinic. PATIENTS: The intervention/pharmacist and the control/ no-pharmacist (provider) group included patients new to the clinic 50 years of age or older from over the span of 4 months. Patients who the pharmacist was unable to reach and those who missed appointments with the provider were excluded. INTERVENTIONS: The pharmacist phoned new patients approximately one week prior and one week after their first appointments with a provider. MAIN OUTCOME MEASURE: Primary outcome: number of drug-related problems (DRPs) detected by the pharmacist compared with the provider. Secondary outcomes: number of medication history discrepancies, accepted medication-related recommendations, potentially inappropriate medications (PIMs) deprescribed, and adverse drug reactions (ADRs) detected. RESULTS: In the intervention/pharmacist (n = 204) vs control/no pharmacist (n = 200) groups, the number of DRPs was significantly greater (338 vs 218; P = 0.031) and driven by unnecessary drug therapies, doses too high, ADRs, and drug-drug interactions (230 vs 147, P = 0.045; 37 vs 7, P = 0.010; 36 vs 17, P = 0.023; 32 vs 1, P = 0.003, respectively). The difference in number of recommendations made by the pharmacist vs medication changes made by the provider was significant: 457 vs 319, P < 0.001, respectively. CONCLUSIONS: The addition of a clinical pharmacist conducting telepharmacy at a geriatrics assessment clinic had a positive impact on patient care as it relates to DRPs, deprescribing PIMs, and optimizing medication adherence. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the efficacy and safety of megestrol for off-label use in older patients with weight loss. DESIGN: Retrospective, nonblinded cohort study. SETTING: Upstate University Hospital is a 420-bed facility and academic medical center with a level 1 trauma center. Upstate Community Hospital is a 314-bed acute care/hospital/ambulatory care center and long-term care hospital that also provides teaching services. PARTICIPANTS: Patients 65 years of age and older without malignancy or acquired immunodeficiency syndrome who were initiated and continued megestrol therapy at the Upstate University hospitals for at least two weeks were included. Of the 1,290 patients initially screened, 16 patients on megestrol were evaluated. An age- and gender-matched control group of 16 patients was utilized for comparison of changes in weight and other variables. INTERVENTIONS: Patients in the megestrol group have received daily doses of megestrol between 160 mg to 800 mg for an average duration of 19 days. Patients in the control group had no history or current use of megestrol utilization. MAIN OUTCOME MEASUREMENTS: The primary outcome was an increase in weight. Secondary outcome measures included albumin and thromboembolic events. Changes in weight and albumin were also compared with the control group. RESULTS: At a mean duration of 19 days, there was no significant difference in weight gain (0.95 kg, OR = 1.33 [95% CI -1.615-3.527]). Albumin decreased by (0.4 g/dL OR = 0.916 [95% CI 0.12-0.78]) and none of the patients developed a thromboembolic event. CONCLUSION: In older hospitalized patients, megestrol did not increase weight, and did not improve albumin. No thromboembolic events were observed, but this may be because of a limited duration of observation of therapy and the routine use of anticoagulation prophylaxis in the inpatient setting. [ABSTRACT FROM AUTHOR]

The article informs about responds to Dr. Eva Stachler's positive letter and emphasizes the importance of both prescribing appropriate medications and deprescribing inappropriate ones. Topic include It cites examples of pharmacist-driven deprescribing programs and initiatives, highlighting their effectiveness in reducing the use of targeted inappropriate medications. It encourage pharmacists to advocate for older patient populations and expand their roles in improving care for this demographic.

Context: Polypharmacy, referring to multiple medications or the use of more drugs than are medically necessary, may lead to undesirable consequences, increasing the risk of adverse drug effects and leading to increases in falls and hospitalizations among older persons. Our objective was to retrospectively determine whether a pragmatic deprescribing protocol reduced 8 common classes of medications in two skilled nursing facilities (SNFs) in a single system. Objective: To determine whether a deprescribing effort reduced several key classes of medications, and the overall number of medication classes per patient, among long-term residents of SNFs. Study Design and Analysis: Retrospective, longitudinal pre/post evaluation. Data from before and during the implementation of the deprescribing effort (2018-2019) were compared with post-intervention years (2020-2021). Setting and Populations Studied: Long-term resident data reported through annual comprehensive minimum data set (MDS) reviews conducted at two SNFs located in central New York State between 2018 and 2021 (N=11,862). Intervention/Instrument: Multi-faceted, pragmatic interdisciplinary deprescribing effort to reduce medications in SNF residence including clinician education, guideline development, and individual chart reviews began in 2019. Outcome Measures: Overall percentage of patients on each of eight classes of medications, compare between pre- and post-intervention periods via cross-tabulation with chi-square. Mean total medication classes for each patient compared pre/post via one-way Analysis of Variance (ANOVA). Results: Mean number of medications were lower, post-intervention, at both facilities (mean=1.88 pre vs. 1.85 post, NS). Significant drops were observed in 4 of 8 categories, including Diuretics (-3.7%, p=.001), Opioids (-4.9%, p=.001), Antipsychotics (-2.0%, p=.002), Antibiotics (-1.6%, p=.045). Antianxiety medications were non-significantly reduced by 0.5%. Antidepressant usage increased (4.6%, p<.001), as did Anticoagulants (4.4%, p<.001). Hypnotic usage went up slightly, but was rare in both periods (0.9% pre vs. 1.4% post, p=.004), and represents a real difference of 3 patients in total. Conclusions: A combined, comprehensive approach to deprescribing was associated with a reduction in overall number of medication classes per resident and in several key classes of medications. Antidepressant usage likely increased as a safer offset to reductions in higher risk medications. [ABSTRACT FROM AUTHOR]

The article discusses the outbreaks that have been linked to compounding pharmacies in the U.S. An example of outbreak include an outbreak of fungal meningitis related to contaminated methylprednisolone. A call for action at the federal and state levels require large-scale compounders be regulated by the U.S. Food and Drug Administration. Critical factors that require close attention include addressing injectable products compounded in outpatient health-care facilities.

Background. The use of sodium polystyrene sulfonate in decreasing serum potassium has recently been questioned due to the lack of documented effectiveness. Methods. A retrospective cohort analysis of all hospitalized patients who received sodium polystyrene sulfonate over four months was performed. The change in serum potassium was noted over a period of 24 hours. Patients who received any other form of potassium-altering drug or treatment were excluded. Results. The administration of sodium polystyrene sulfonate reduced serum potassium by 16.7% (P < 0.001) as compared to the baseline serum potassium over a period of 24 hours. During this same time, no change in serum creatinine was identified (P = 0.73). In addition, there was no correlation between potassium and creatinine change (r2 = 0.0004 and P = 0.99). Patients with higher initial serum potassium (⩾5.6 mEq/L) reduced their potassium concentration 4% more than those with initial serum potassium of <5.6mEq/L; however, this reduction did not reach statistical significance (P = 0.32). There was no significant difference in the effectiveness of 15 gm and 30 gm resin preparation (P = 0.54). Thirteen deaths were noted in our cohort, of which one death was due to ischemic colitis. Conclusion. We conclude that sodium polystyrene sulfonate is effective in lowering serum potassium. [ABSTRACT FROM AUTHOR]

Background. The use of sodium polystyrene sulfonate in decreasing serum potassium has recently been questioned due to the lack of documented effectiveness. Methods. A retrospective cohort analysis of all hospitalized patients who received sodium polystyrene sulfonate over four months was performed. The change in serum potassium was noted over a period of 24 hours. Patients who received any other form of potassium-altering drug or treatment were excluded. Results. The administration of sodium polystyrene sulfonate reduced serum potassium by 16.7% (P < 0.001) as compared to the baseline serum potassium over a period of 24 hours. During this same time, no change in serum creatinine was identified (P = 0.73). In addition, there was no correlation between potassium and creatinine change (r2 = 0.0004 and P = 0.99). Patients with higher initial serum potassium (⩾5.6 mEq/L) reduced their potassium concentration 4% more than those with initial serum potassium of <5.6mEq/L; however, this reduction did not reach statistical significance (P = 0.32). There was no significant difference in the effectiveness of 15 gm and 30 gm resin preparation (P = 0.54). Thirteen deaths were noted in our cohort, of which one death was due to ischemic colitis. Conclusion. We conclude that sodium polystyrene sulfonate is effective in lowering serum potassium. [ABSTRACT FROM AUTHOR]

The use of nesiritide for acute decompensated heart failure (ADHF) has been clouded with controversy since its approval in 2001. Extensive marketing and many review articles have established this drug as a safe and superior product to current standards. However, its safety has been called into question by the results of a meta-analysis, and its superiority of important outcomes (length of stay, mortality, decreased readmission rate) has never been proved by a randomized trial against agents with similar vasodilator properties (e.g., nitroglycerin). A review of the available literature on nesiritide in the areas of mortality, renal effects, retrospective studies, use in off-label indications, length of stay, and mortality is presented and illustrates why its use should be limited or even eliminated. After review of this article, the reader should be able to answer the question--if nesiritide had never been approved for use in patients with ADHE would we have missed it?--with a negative reply. [ABSTRACT FROM AUTHOR]

Introduction and Objective: The literature has suggested that many medications commonly used in long term care settings could be simplified or eliminated. While the importance of minimizing medications is well understood there is a lack of specific recommendations to assist with this task. The purpose of this study was to evaluate the usefulness of a medication reduction protocol in a long term care facility. Methods: A medication review, with a set of predetermincd criteria to guide decision-making, was applied to 54 skilled nursing care residents, over a 7-month period. The protocol examined certain medications commonly used in long term care and specified criteria to make an intervention. Changes in medication use, cost savings, and adverse effects were examined 3 months after the medication changes were initiated. Results and Conclusions: A total of 84 changes were made on 81% (N = 44) of residents, averaging 1.6 changes per patient. Interventions resulted in an 8% reduction in the number of medications and a 12% reduction in the number of doses per patient per day over a 3-month period. Ninety-four percent of the changes were still in effect at 3-month follow-up. Overall, this resulted in an annual cost saving of $2190 for 54 residents. This study suggests that many medications commonly used in long term care can be safely eliminated and drug scheduling can be optimized. [ABSTRACT FROM PUBLISHER]

Presents information on nesiritide, a recombinant form of human B-type natriuretic peptide approved by the U.S. Food and Drug Administration for the treatment of acute decompensated chronic heart failure. Safety and efficacy of nesiritide; Economic factors that must be considered in taking the drug;

A letter to the editor is presented in response to the article "Compounding Pharmacy Conundrum: "We Cannot Live Without Them But We Cannot Live With Them" According to the Present Paradigm," by R. Guharoy, J. Noviasky, Z. Haydar and colleagues in the April 2013 issue, along with a response from authors of the article.

This article discusses some studies on the use of anticoagulation with warfarin to prevent ischemic stroke recurrence. Details of how the studies were conducted are given. Warfarin was found not effective in preventing ischemic stroke. Furthermore, anticoagulation significantly increases the risk of fatal and nonfatal hemorrhagic stroke and extracranial hemorrhage in patients.

Focuses on utilization of tadalafil, a reversible phosphodiesterase type 5 inhibitor, for the treatment of erectile dysfunction. Dose-related side effects of the drug; Percentage of men in the tadalafil group who reported an erection suitable for insertion; Cost of the drug per dose.