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Objective: To describe consumer understanding of pharmacy quality measures and consumer preferences for pharmacy quality information. Methods: Semi-structured focus group design was combined with survey methods. Adults who filled prescription medications for self-reported chronic illnesses at community pharmacies discussed their understanding of Pharmacy Quality Alliance approved quality measures. Questions examined preference of pharmacy quality information rating systems (e.g. stars versus percentages) and desired data display/formats. During the focus group, participants completed a survey examining their understanding of each pharmacy quality measure. All focus group discussions were transcribed verbatim. Data were analyzed using thematic analysis and descriptive statistics. Results: Thirty-four individuals participated (mean age= 62.85; SD=16.05). Participants were unfamiliar with quality measures information and their level of understanding differed for each quality measure. Surveys indicated 94.1% understood “Drug-Drug Interactions” and “Helping Patients Get Needed Medications” better than other measures (e.g., 76.5% understood “Suboptimal Treatment of Hypertension in Patients with Diabetes”). Qualitative analysis indicated participants preferred an overall pharmacy rating for quick access and use. However, participants also wanted quality measures information displayed by health conditions. Participants favored comparison of their pharmacy to city data instead of state data. Most participants liked star ratings better than percentages, letter grades, or numerical ratings. Conclusions: Individuals who have a chronic illness and regularly use community pharmacies are interested in pharmacy quality measures. However, specific quality measures were not understood by some participants. Participants had specific preferences for the display of pharmacy quality information which will be helpful in the design of appropriate quality report systems.

Background: Paracetamol (acetaminophen) is the most common cause of acute liver failure (ALF). ALF attributed to paracetamol is most often associated with the following features: an unintentional overdose, a single product, an opioid-paracetamol combination, duration of <7 days, and a median dose of 7.5 g/day. Currently, the recommended maximum daily dose of paracetamol is 4 g.Objectives: The aims of the study were to determine opioid-paracetamol prescription patterns, including prescriptions exceeding the recommended dose of paracetamol (4 g/day) [prescriptions and beneficiaries]; examine factors associated with receiving opioid-paracetamol prescriptions in excess of paracetamol 4 g/day; and evaluate opioid-paracetamol prescription patterns for beneficiaries with liver dysfunction.Methods: A retrospective cohort study examining prescription data of 4.8 million beneficiaries from a US health benefits organization from 1 January 2009 through 31 December 2009. The main outcomes examined were daily paracetamol dose and liver dysfunction.Results: A large proportion (8.1%) of the 5.3 million prescriptions for opioid-paracetamol exceeded the recommended maximum daily dose of paracetamol (4 g/day), putting over one-quarter of a million (255 123 [18.9%]) of the 1.35 million beneficiaries receiving an opioid-paracetamol prescription at risk of toxicity. The most frequently prescribed products that exceeded paracetamol dose guidelines contained dextropropoxyphene and hydrocodone. Multiple factors, including type of product (i.e. dextropropoxyphene or oxycodone-containing), geographical location (Midwest), strength of the paracetamol in the opioid-paracetamol product (>325 mg) and prescriber specialty (dentist, physician assistant), were associated with high-dose paracetamol prescriptions. Liver dysfunction was diagnosed in 3818 cases, and 23.4% of these beneficiaries received an opioid-paracetamol prescription in the 90 days prior to the liver dysfunction diagnosis.Conclusions: Although most opioid-paracetamol prescriptions are written and dispensed for <4 g/day of paracetamol, a significant portion of beneficiaries are being prescribed and dispensed excessive doses of paracetamol. Efforts to curtail this practice may involve provision of prescriber and pharmacist education, utilization of benefit manager systems to flag excessive dosing or that require confirmation of dosing, and implementation of US FDA recommendations supported by these data. [ABSTRACT FROM AUTHOR]

Background: The Affordable Care Act (ACA) initiated federally and state-run health insurance exchanges, or marketplaces, with health plans offering subsidies for plan members as well as coverage for essential health benefits, to help individuals, families, and small businesses find health plans that fit their specific needs. A recent study found that the value of these healthcare subsidies varied with the number of health plans in the different geographic rating areas, but that study only examined the premiums and the deductibles of those health plans., Objectives: To examine the value of subsidies of health plans, including cost-sharing for prescription drugs in the health insurance marketplace., Methods: We have used publicly available health plan data from HealthCare.gov and from county population data obtained from the US Census Bureau in June 2015. The average-weighted premium; medical deductible; medical maximum out-of-pocket spending; and cost-sharing for generic drugs, preferred and nonpreferred brand-name drugs, and specialty drugs were calculated for the second lowest-cost silver plan in each geographic rating area. These were then compared across geographic areas with different numbers of plans to determine the value of the subsidies. We also compared the difference between the cost of the average silver plan and the second lowest-cost silver plan for each area to determine the cost to enrollees if they selected the average silver plan., Results: The monetary value of the subsidies provided by health plans was lower in areas with a larger number of plans, because the second lowest-cost silver plans in these areas tended to have lower premiums and higher deductibles. For the most common type of cost-sharing for generic and for preferred brand-name drugs, plan enrollees would likely have a lower or similar copayment if they selected the average-cost silver plan instead of the second lowest-cost silver plan. However, they may end up paying approximately $8 less in copayment for nonpreferred branded drugs and approximately 4% less for coinsurance after a deductible for specialty drugs if they resided in a geographic area with fewer than 11 plans., Conclusion: The value of subsidies provided by the ACA-initiated health plans in the healthcare marketplace, including cost-sharing for prescription drugs, varies across geographic areas with different numbers of health plans. This suggests that potential enrollees should consider cost-sharing for prescription drugs in addition to health plans' premiums and deductibles when choosing their health plan.

Objective: To examine the relationship between students' prepharmacy repeat course history and their academic difficulties early in a professional pharmacy program in conjunction with other prerequisite success variables known to predict academic difficulty., Methods: For students admitted to a pharmacy program in 2010 and 2011 (n=160), admission variables [eg, prepharmacy coursework, grade point average (GPA)] and pharmacy program academic difficulty data (ie, academic difficulty defined as a pharmacy GPA in the bottom quartile of the class after 3 semesters of pharmacy course work) were extracted. Regression analysis was employed to examine the relationship between admission variables and academic difficulty., Results: Twenty-six percent of the students (n=42) repeated a course, and 50% of these students (n=21) repeated more than one course. All of the admissions variables studied were found to individually increase the odds of a student having academic difficulty early in the pharmacy program. Specifically, repeat of a prepharmacy course increased the odds of academic difficulty threefold., Conclusion: Repeating prepharmacy coursework appears to be a strong indicator of future academic difficulties early in a professional pharmacy program.

Consensus exists regarding the need to reduce antipsychotic medication use in nursing homes, multiple initiatives have been implemented with the intent to achieve this goal, and progress is being made. While limited high quality research is available documenting the impact of various approaches, resource tool kits and best practice descriptions can help guide efforts.

Objective: To describe patients' perceived value and use of quality measures in evaluating and choosing community pharmacies., Design: Focus group methodology was combined with a survey tool. During the focus groups, participants assessed the value of the Pharmacy Quality Alliance's quality measures in evaluating and choosing a pharmacy. Also, participants completed questionnaires rating their perceived value of quality measures in evaluating a pharmacy (1 being low value and 5 being high) or choosing a pharmacy (yes/no). Thematic analysis and descriptive statistics were used to analyse the focus groups and surveys, respectively., Setting: Semistructured focus groups were conducted in a private meeting space of an urban and a rural area of a Mid-western State in the USA., Participants: Thirty-four adults who filled prescription medications in community pharmacies for a chronic illness were recruited in community pharmacies, senior centres and public libraries., Results: While comments indicated that all measures were important, medication safety measures (eg, drug-drug interactions) were valued more highly than others. Rating of quality measure utility in evaluating a pharmacy ranged from a mean of 4.88 ('drug-drug interactions') to a mean of 4.0 ('absence of controller therapy for patients with asthma'). Patients were hesitant to use quality information in choosing a pharmacy (depending on the participant's location) but might consider if moving to a new area or having had a negative pharmacy experience. Use of select quality measures to choose a pharmacy ranged from 97.1% of participants using 'drug-drug interactions' (medication safety measure) to 55.9% using 'absence of controller therapy for patients with asthma'., Conclusions: The study participants valued quality measures in evaluating and selecting a community pharmacy, with medication safety measures valued highest. The participants reported that the quality measures would not typically cause a switch in pharmacy but might influence their selection in certain situations., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

In 2012, the Centers for Medicare & Medicaid Services (CMS) established a partnership among stakeholders to decrease the percentage of residents in nursing homes receiving an antipsychotic agent by 15 percent. This goal emanated from concerns including the large percentage of residents taking antipsychotic agents, the questionable use of antipsychotics (e.g., off-label use), the high cost of inappropriate antipsychotic use, and toxicity in patients with dementia (e.g., black box warning regarding mortality). The successful achievement of this goal is evaluated via quality measures, which are greatly influenced by changes in exclusion of residents from the population examined. The partnership is focused on optimizing use of antipsychotic agents by training clinicians on nonpharmacologic approaches, educating on the dangers of antipsychotic medication use and sharing data on antipsychotic medications. In South Dakota, these efforts have yielded a 12 percent relative reduction (21.3 percent to 18.7 percent) in the percent of residents prescribed antipsychotic agents from the second quarter of 2012 to the second quarter of 2013. Future efforts in South Dakota include a Nursing Home Quality Care Collaborative that involves the majority of facilities across the state learning from peers and national experts. The South Dakota Dementia Coalition includes 17 stakeholders who guide education activities and communicate these opportunities to their constituents.

Objectives: To describe consumers' ability to interpret pharmacy quality measures data presented in a report card, to examine the tools that consumers require to interpret the information available in a pharmacy quality report card, and to determine whether pharmacy quality measures influence consumers' choice of a pharmacy., Design: Qualitative study., Setting: Three semistructured focus groups conducted in a private meeting space at a public library in Sioux Falls, SD, from April 2011 to May 2011., Participants: 29 laypeople., Intervention: Participants' skills interpreting and using pharmacy quality information were examined based on mock report cards containing the Pharmacy Quality Alliance (PQA) quality measures., Main Outcome Measures: Consumer perceptions of pharmacy quality data., Results: Participants reported difficulty understanding quality measures because of knowledge deficits. They wanted supportive resources on drug class of their medications to help them understand the measures. Participants had different opinions on whether their pharmacies should be compared with other pharmacies based on specific quality measures. For example, they favored the use of drug-drug interactions as a quality measure for comparing pharmacies, while medication adherence was deemed of limited use for comparison. Participants stated that pharmacy report cards would be useful information but would not prompt a change in pharmacy. However, participants perceived that this information would be useful in selecting a new pharmacy., Conclusion: The results suggest that consumers require simplification of PQA quality measures and supportive resources to interpret the measures. Consumers may favor certain quality measures based on their perception of the role of the pharmacist. Education is required before full use of this quality-of-care information can be realized.

Objective: Review the current Centers for Medicare & Medicaid Services' (CMS) Interpretive Guidelines from the State Operations Manual (SOM) in light of evidence for management of depression found in the literature., Data Sources: Articles indexed in PubMed for the last 20 years, American Psychiatric Association Guidelines, CMS Interpretive Guidelines from the SOM, and The American Medical Directors Association (AMDA) Guidelines., Study Selection and Data Extraction: Forty published papers were reviewed, and criteria supporting the primary objective were used to identify useful resources., Data Synthesis: The literature included guidelines regarding the management of late-life depression (e.g., dosage and duration of therapy). This literature was examined in relation to the current CMS Interpretive Guidelines, which are provided to state surveyors to help them evaluate whether a nursing facility is in compliance with federal regulations. These guidelines provide explanation and clarification of the actual regulations and so are used during evaluation of the facility., Conclusion: Current recommendations indicate that a first episode of depression should be treated for 12 months beyond full remission, according to AMDA guidelines. Longer treatment durations (maintenance phase) are needed depending on the resident's situation (e.g., severity or number of episodes). In addition, evidence suggests that antidepressants should remain at the same dose through the maintenance phase of treatment. The Interpretive Guidelines require a dosage reduction to the lowest effective dose by decreasing the dose two times in the first year unless "clinically contraindicated to discontinuation" is documented. This correlates to a dosage reduction within the first nine months of antidepressant treatment. This necessitates that in the majority of depressive episodes, clinicians document their rationale for continuing treatment. Clinicians must commit to this process, and surveyors must acknowledge this appropriate approach to depression management.

Objective: To examine the impact of implementation of the Accreditation Council for Pharmacy Education's (ACPE's) Standards 2007 on pharmacy students' preparation for their first advanced pharmacy practice experience (APPE)., Design: The doctor of pharmacy (PharmD) curriculum was altered to include introductory pharmacy practice experiences (IPPE), second-year therapeutics, classroom integration of practice experiences, more biomedical sciences, an electronic portfolio system, life-long learning exercises, and additional content based on Appendix B of Standards 2007. Curricular outcomes and the assessment plan also were revised based on Standards 2007., Assessment: To evaluate the impact of these changes to the curriculum, faculty members rated 9 behaviors of students observed during the third week of their first APPE and compared their scores with those of students who were evaluated in 2004 before the curriculum had been revised. Students completing the revised curriculum performed all 9 behaviors more often and had a better average score than students evaluated in 2004., Conclusion: Curricular revisions implemented to address ACPE Standards 2007 were associated with positive clinical behaviors in students beginning their experiential education.

Objectives: To determine the ability of first-year students to self-assess communication skills and measure the impact of video review on students' self-assessment., Design: Students participated in a digital video-recorded, counseling-simulation exercise and completed self-assessment before and after viewing their video. A faculty member evaluated the students using the same counseling assessment tool., Assessment: Correlation between the students' self-assessment scores and the faculty member's scores were poor (pre-video: r = 0.38, post-video: r = 0.46). The largest portion of the students overestimated their skills in comparison to the faculty member's evaluations (47.1% pre-video and 67.9% post-video). Those in the lowest quartile overestimated their skills, while those in the upper quartile underestimated their skills (pre-video). Video review brought about an increase in the self-assessment scores for nearly two-thirds (62.1%) of the students., Conclusion: First-year pharmacy students had difficulty self-assessing, and video review increased their perception of skill achievement. A curriculum should include opportunities for students to develop self-assessment skills early in the program, and this should be reinforced throughout the curriculum.

Objective: To determine the impact of an introductory pharmacy practice experience (IPPE) on students' clinical skills during their initial advanced pharmacy practice experience (APPE)., Design: A 4-week First Steps course that focused on students developing pharmacy practice skills, clinical communications skills, and effective use of reference materials was introduced in 2006 at the end of the third-year curriculum, prior to students beginning their APPEs., Assessment: During the third week of the first APPE, faculty members rated students' demonstration of 9 clinical skills on a 5-point Likert scale (1 being always and 5 being never). The evaluation was performed in 2005 prior to implementation of the course (control group) and again in 2006 after implementation of the course. Students who completed the First Steps course scored better on all 9 skills and had a better average clinical skills value (2.3) compared to the control group (2.6, p < 0.01)., Conclusion: Completion of an IPPE course that focused on critical pharmacy practice aspects, clinical communication skills, and use of reference materials resulted in increased frequency of desired clinical behaviors on a subsequent APPE.

Optimizing medication use through the evaluation of Potentially Inappropriate Medications (PIMs) has been the focus of a great deal of research. The Centers for Medicare & Medicaid Services (CMS) has created its own definition of PIMs from a variety of existing criteria and has contracted with each state's Quality Improvement Organization (South Dakota Foundation for Medical Care in South Dakota) to work on reducing PIM rates. In South Dakota, 16.4 percent of Medicare beneficiaries who filled a prescription (April 1, 2008, through September 30, 2008) received a PIM. Of the patients receiving PIMs, 13.6 percent received PIMs from two or more categories, and 88.3 percent filled a prescription for at least one of the five most common PIM categories. These five PIM categories were propoxyphene, skeletal muscle relaxants (select agents), nitrofurantoin, oral estrogens and antihistamines (select agents). While there may be rare occasions when these agents are justified, safer or more effective alternatives exist.

Pain is frequently reported and often undertreated in the elderly population. In light of these concerns, it is important to examine potentially ineffective or problematic pain medications. Propoxyphene is one such agent whose efficacy and safety have been questioned by researchers, clinicians and the U.S. Food and Drug Administration (FDA). Specifically, multiple studies have found propoxyphene to be no more effective than acetaminophen (APAP), yet propoxyphene causes opioid side effects and has been involved in many drug-related deaths. In addition, propoxyphene/APAP products are often prescribed at doses that exceed maximum values (49.2 percent of APAP/propoxyphene napsylate 100 prescriptions for South Dakota Medicaid patients exceeded the maximum daily dose). The relevance of propoxyphene use is seen by the 7.1 percent prevalence of propoxyphene prescriptions among the South Dakota Medicare beneficiaries, which is comparable to the 6.8 percent reported in the U.S. community-based Medicare population. Therefore, it is very important to consider alternatives to propoxyphene such as APAP, nonsteroidal anti-inflammatory drugs (rare use due to adverse effects) and other opioids, when managing elderly patients with pain.

Decline among older adults has the potential to produce dramatic changes in the elderly person's life, having an influence on the place of residence, self-sufficiency, and quality of life. Although the prevalence of decline among the elderly had decreased, the relevance of this topic will continue to grow with the expansion of the elderly population. It is important to understand the terminology used to describe decline, how it is measured, its ramifications, associated risk factors, and potential causes in order to participate in preventing and managing decline. Pharmacists should also be aware of the relationship of medications to decline including the management of causative conditions and medication-use patterns that are associated with decline. Finally, pharmacists must be prepared to help elderly patients who are having difficulties administering medications as a result of decline.

Objective: To determine whether patients should wait 30 minutes after caffeine consumption to have their blood pressure measured., Data Sources: Literature was obtained by searching MEDLINE (1980-September 2007), International Pharmaceutical Abstracts (1980-September 2007), and the Cochrane Database of Systematic Reviews (1994-September 2007). Search terms included caffeine and blood pressure. Literature was also obtained from citations in relevant articles., Study Selection and Data Extraction: Articles that examined caffeine's acute effect on blood pressure were reviewed, with additional focus on caffeine tolerance and hypertensive status., Data Synthesis: Caffeine appears to affect blood pressure through adenosine receptor inhibition and an increased release of select neurotransmitters. Caffeine levels peak 30-120 minutes after oral intake and caffeine's half-life is 3-6 hours. The effect of caffeine on blood pressure has been examined for decades, with variable results depending on factors such as population examined (eg, hypertensive status, physical stressors, age) and study design (eg, acute effects, chronic ingestion, retrospective epidemiologic review). Caffeine tolerance diminishes the acute effect of caffeine on blood pressure, and hypertensive individuals are more susceptible to blood pressure changes. Reviews of caffeine's acute effect on blood pressure indicate changes of 3-15 mm Hg systolic and 4-13 mm Hg diastolic. Typically, blood pressure changes occur within 30 minutes, peak in 1-2 hours, and may persist for more than 4 hours., Conclusions: Having a patient abstain from caffeine for 30 minutes prior to blood pressure monitoring is not adequate to avoid caffeine's potential effects. An alternative approach to blood pressure monitoring would be to ask the patient about recent caffeine consumption and interpret the blood pressure reading based on this information. In addition, healthcare practitioners should provide education regarding caffeine's effects.

Objectives: To determine the extent to which therapeutics textbooks address age-related medication information., Methods: Criteria for 5 disease states prevalent among geriatric patients were developed based on the content of a geriatric textbook and from expert reviewers' input. The criteria were used to determine the degree to which geriatric content was addressed in 3 therapeutics textbooks., Results: The therapeutics textbooks contained less than half of the critical points for 3 disease states: chronic obstructive pulmonary disease, heart failure, and diabetes mellitus (31%, 33%, and 46%, respectively). In addition, the textbooks addressed only one half to two thirds of the criteria for the remaining 2 disease states of osteoarthritis and dementia (55% and 68%, respectively). Criteria specific to the elderly were addressed less often than criteria that were important but not unique to the elderly (38% and 63%, respectively)., Conclusions: Current therapeutics textbooks have significant gaps in geriatric medication information. Users of these textbooks must supplement them with primary literature or a geriatric textbook for more comprehensive medication therapy management information.

Objective: To evaluate the evidence of an interaction between selective serotonin reuptake inhibitors (SSRIs) and nonsteroidal antiinflammatory drugs (NSAIDs) producing an increased risk for gastrointestinal adverse outcomes such as bleeding., Methods: We searched MEDLINE for English-language literature published between 1966 and August 2005. All studies examining gastrointestinal adverse effects from an SSRI-NSAID combination were included., Data Synthesis: Four retrospective studies examined gastrointestinal adverse outcomes from the combination of SSRIs and NSAIDs. The risk ratio for an upper gastrointestinal bleed from this drug combination (compared with not receiving either agent) ranged from 3.3-15.6, and the risk ratio for gastrointestinal adverse effects was 12.4. Two studies found that the risk for an upper gastrointestinal bleed from the drug combination exceeded the additive risk of the agents alone. The risk ratio for an upper gastrointestinal bleed from an SSRI-aspirin interaction was 1.9-7.2. In addition, the number needed to harm in terms of an upper gastrointestinal bleed from an SSRI-NSAID combination ranged from 62-75 patient-years, and the number needed to harm for gastrointestinal adverse effects was 2 patient-years., Conclusion: Concurrent use of an SSRI and NSAID increases the risk of gastrointestinal adverse outcomes such as bleeding. Clinicians must take care to avoid these negative outcomes by altering NSAID or SSRI therapy, or by providing ulcer-protective drugs.

Background: Polypharmacy has been extensively studied internationally and reported to be increasing among the elderly. Within the United States, few studies have examined polypharmacy trends in the elderly population and even fewer studies addressed those at-risk for polypharmacy., Objectives: To examine the trends in office-based visits in the United States by the elderly involving polypharmacy and identify elderly at-risk for polypharmacy., Methods: Data from the 1990 and 2000 National Ambulatory Medical Care Surveys were used to examine polypharmacy visit trends in the elderly. The Bonferroni inequality method was used to analyze the visit estimates and visit rates. Logistic regression analysis was used to model predisposing, enabling, and need factors associated with polypharmacy visits in the elderly using the 2000 survey data., Results: Office visits involving polypharmacy for elderly patients were estimated to have nearly quadrupled from 10.1 million in 1990 to 37.5 million in 2000. The proportion of visits by elderly patients involving polypharmacy was 7% in 1990 and 19% in 2000. The increase was consistent among all demographic groups and remained significant even after controlling for elderly population increase. Medication classes involved in polypharmacy remained consistent during the study period and included cardiovascular, hormonal, pain, and gastrointestinal medications. Analysis of the 2000 survey data revealed that several need (multiple diagnoses, chronic problems, and specific disease states), predisposing (female gender), and enabling factors (primary care provider visit and health insurance coverage) were associated with polypharmacy visits in the elderly., Conclusions: The study found a significant increase in elderly patients' office visits involving polypharmacy in the United States. The study also found that several need, predisposing, and enabling factors were associated with polypharmacy visits in the elderly. These findings suggest opportunities to review and manage elderly patients' medications as recommended by Healthy People 2010, a national agenda to improve the health of Americans.

Background: Previous applications of the Beers criteria have shown significant prescribing of potentially inappropriate psychotropic agents for the community-dwelling elderly. However, there is limited information at the national level on potentially inappropriate psychotropic use, the characteristics of elderly persons at risk, and the impact of this inappropriate use on health care outcomes., Objective: This study addressed the prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use among community-dwelling elderly persons in the United States who were receiving psychotropic medications., Methods: Data from the 1996 Medical Expenditure Panel Survey (MEPS) were employed to examine the use of psychotropic medications that generally should be avoided in the elderly and those that should be avoided in elderly patients with certain preexisting conditions, as defined by the Beers criteria. The MEPS sampling weights were used to derive national estimates. Cross-sectional data were analyzed by multivariate analyses to examine the correlates and associated health care outcomes (health care utilization, economic, and humanistic) of potentially inappropriate psychotropic use in the elderly., Results: An estimated 2.30 million community-dwelling elderly persons received potentially inappropriate psychotropic medications in 1996. This represented 7.14% of all community-dwelling elderly persons and 37.86% of all community-dwelling elderly persons using psychotropic agents; 32.94% of those taking psychotropic drugs received agents that were generally inappropriate, and 10.21% received agents that were inappropriate in the presence of specific conditions. The rates of potentially inappropriate psychotropic use in those receiving antidepressant, antianxiety, and sedative/hypnotic agents were 50.93%, 31.84%, and 23.49%, respectively. Multivariate analyses showed that correlates of potentially inappropriate psychotropic use in the elderly were age <75 years and use of multiple psychotropic agents. After controlling for predisposing, enabling, and need factors, no association was found between the use of potentially inappropriate psychotropic medications and differences in health care utilization, economic, or humanistic outcomes., Conclusions: The study findings suggest that although the use of potentially inappropriate psychotropic medications is common among the community-dwelling elderly who are prescribed psychotropic agents, the unfavorable risk-benefit ratio of these inappropriate medications does not appear to influence broad measures of health care utilization, costs, or quality of life in this population.

Objective: To examine the identification of conditions, the evaluation of these conditions as adverse drug reactions (ADRs), and the communication practices regarding suspected ADRs in a long-term care (LTC) facility., Design and Setting: Health care providers completed a survey containing nine questions covering 13 conditions, about residents of a 99-bed LTC facility., Participants: Twenty-five health care providers (i.e., CNAs, LPNs, RNs, RPh, social workers, and an activities worker) reviewed residents on their units. A total of 67 residents were reviewed., Results: The RPh was aware of fewer of the residents' conditions (16% of all conditions) compared with CNAs (34%), LPNs (38%), and RNs (45%). RNs and the RPh identified an equal percent of conditions that could be caused by a resident's medications (66.5% and 66.7% of all conditions, respectively). This was greater than LPNs (36%) or CNAs (9.9%). However, RNs and the RPh actually attributed a lower percentage of these conditions to the medications (43.9% and 41.7%, respectively) compared with LPNs (57.4%) and CNAs (90.0%). CNAs notified others in a higher percentage of the cases where they suspected an ADR (81.5%) compared with the RPh (60%), RNs (57.4%), or LPNs (10.3%). No notification was primarily attributed to "nothing could be done," the condition is an expected effect, others were aware of the condition, and the condition currently is being treated., Conclusions: These results illustrate the importance of a team approach to ensure that all health care providers are aware of conditions to properly evaluate and resolve them.

Objectives: To examine psychotropic prescription use in community-dwelling elderly in the United States and its association with predisposing, enabling, and need factors., Design: Retrospective analysis of the 1996 Medical Expenditure Survey (MEPS)., Setting: A national representative sample survey of the United States non-institutionalized population., Participants: Community-dwelling persons aged 65 and older participating in the MEPS., Measurements: Psychotropic prescription use patterns and factors associated with the use of psychotropics in general as well as of individual classes, specifically antidepressants, antianxiety agents, and sedative/hypnotics., Results: According to the MEPS, more than 6 million (19%) community-dwelling elderly persons used psychotropic medications in 1996. Nearly 3 million (9.1%) elderly were taking antidepressants, almost 2.5 million (7.5%) antianxiety agents, and 1.5 million (4.8%) sedative/hypnotics. Several correlates of psychotropic prescription use were identified. Enabling (e.g., prescription insurance) and need (e.g., health status) factors were found to be consistently associated with the use of antidepressant, antianxiety, and sedative/hypnotic agents. Predisposing factors such as sex, race, region, and education varied with the type of psychotropic drug class examined., Conclusion: Nearly one in five community-dwelling elderly persons used psychotropic medications, primarily antidepressants followed by antianxiety agents. Enabling and need factors were consistently associated with psychotropic classes examined, whereas most predisposing factors varied with the type of psychotropic drug class.

Psychotropic medications are an important treatment approach to mental health disorders; such disorders are common in the elderly population. Elderly patients are more likely to experience adverse effects from these agents than their younger counterparts due to age-related changes in pharmacodynamic and pharmacokinetic parameters. Because of these factors, inappropriate use of psychotropic medications in elderly patients has become a focus of concern. In general an agent is considered inappropriate if the risk associated with its use exceeds its benefit. Implicit and explicit criteria for inappropriate use of medications in the elderly have been created and include psychotropic agents. These criteria vary in their make-up but the explicit criteria tend to agree that amitriptyline, doxepin, and benzodiazepines that have long half-lives are not appropriate. Although explicit inappropriate medication criteria have been in existence since 1991, elderly patients continue to receive inappropriate psychotropic medications. A wide array of factors may be responsible for this practice. Provider-related causes include deficits in knowledge, confusion due to the lack of a consensus on the inappropriate psychotropic criteria, difficulties in addressing an inappropriate medication started by a previous provider, multiple prescribers and pharmacies involved in the care of a patient, negative perceptions regarding aging, and cost issues. Patients may contribute to the problem by demanding an inappropriate medication. Finally, the healthcare setting may inadvertently contribute to inappropriate prescribing by such policies as restrictive formularies or lack of reimbursement for pharmacists' clinical services. Successful approaches to optimising prescribing have been either educational or administrative. Educational approaches (e.g. one-on-one sessions, academic detailing) seek to influence decision making, while administrative approaches attempt to enforce policies to curtail the undesired practice. The US Omnibus Budget Reconciliation Act of 1987, which improved psychotropic medication use in long-term care, is an excellent example of administrative intervention. More research specifically focused on the causes of inappropriate psychotropic medication use and methods to avoid this practice is needed before targeted recommendations can be made.

Background: Psychotropic agents account for 23% to 51% of all inappropriate medications prescribed based on 1991 inappropriate medication criteria for nursing home residents. The criteria were revised to apply to all people older than 65 years. This study used the revised criteria in ambulatory settings to quantify potentially inappropriate prescription of psychotropic agents and identify associated characteristics., Methods: The 1996 public use data files of the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were analyzed for inappropriate prescription of psychotropic medications for the elderly in office-based settings and outpatient departments. Disease-independent and disease-dependent criteria were analyzed., Results: Elderly patients were prescribed a psychotropic agent in 8. 7% of all visits, antidepressant and antianxiety agents being the most frequently prescribed medications. Commonly, elderly patients receiving psychotropic agents were female, white, aged between 65 and 74 years, and received health care in a metropolitan area. Potentially inappropriate psychotropic agents were prescribed in 27. 2% of all visits involving a psychotropic agent for the elderly. Disease-independent criteria (eg, antidepressant agents and long-acting benzodiazepines) accounted for most of the potentially inappropriate prescriptions. Factors positively associated with potentially inappropriate prescriptions included older age, "seen before" status, and antidepressant drug class, while enrollment in Medicaid, antipsychotic drug class, living in the Northeast region, and receiving health care in a metropolitan area were negatively associated., Conclusions: Potentially inappropriate prescription of psychotropic agents is very common for the elderly patient in the ambulatory setting. By focusing on the agents most frequently involved (eg, amitriptyline and long-acting benzodiazepines), provider characteristics (eg, location), and patient characteristics (eg, age), the greatest impact on potentially inappropriate prescribing can be achieved.

Objective: To review currently available literature applying the Beers criteria for inappropriate medication use in the elderly to prescribing practices in various settings., Data Source: Key words including inappropriate, Beers, medication, prescribing, elderly, geriatric, and criteria were used to search MEDLINE records from January 1992 to June 1999., Data Extraction: Eight relevant studies were found that applied the Beers criteria in various healthcare settings., Data Synthesis: Each study was examined for methodologic issues, criteria used, prevalence, nature and extent of inappropriate medication use, and factors associated with their use. Despite the methodologic differences, the review revealed some consistent patterns across healthcare settings. This review has shown that: (1) most of the researchers modified the Beers criteria to examine inappropriate medication use in the elderly; (2) studies using patient-based prevalence showed that between nearly one in four (23.5%) and one in seven (14.0%) elderly patients received an inappropriate medication as defined by either the Beers list of 20 inappropriate medications or the Modified Beers list; (3) the majority of these patients received one inappropriate agent; and (4) long-acting benzodiazepines, dipyridamole, propoxyphene, and amitriptyline were among the most frequently prescribed inappropriate medications. Univariate analyses indicated that women, patients >80 years old, and Medicaid patients appeared to receive more inappropriate medications than others; however, multivariate analyses found that only a higher number of medications was consistently associated with inappropriate medication use., Conclusions: Inappropriate prescribing or use trends are noteworthy because they were observed despite methodologic differences. The findings can be instrumental in developing targeted interventions to influence future prescribing practices. More research is needed to address the national trends and healthcare impact of inappropriate drug use in the elderly.

This study employed data from the National Ambulatory Medical Care Survey (NAMCS) 1995 to (1) determine the prevalence of the prescribing of psychotropic drugs for elderly patients by office-based physicians in the United States; (2) estimate the prevalence of the prescribing of potentially inappropriate psychotropic drugs in this patient population; and (3) identify any factors that predict such prescribing. For the purposes of this study, previously developed consensus criteria were adopted defining inappropriate psychotropic drugs as those that should be avoided in the elderly. According to the NAMCS data, psychotropic medications were prescribed in an estimated 12.02 million visits by elderly patients (95% confidence interval [CI], 11.07-12.97 million). The psychotropic medications most frequently prescribed for elderly patients by office-based physicians were antidepressants and antianxiety agents. The occurrence of visits at which psychotropic medications were prescribed was greater in patients who were over 84 years of age, female, white, or from the western United States. Primary care physicians prescribed the majority of these psychotropic drugs, and most visits to psychiatrists by elderly patients resulted in the prescribing of psychotropic drugs. Office-based physicians prescribed at least one potentially inappropriate psychotropic medication in 2.03 million visits by the elderly (95% CI, 1.70-2.36 million), or 16.87% of visits by the elderly involving prescriptions for psychotropic drugs. The most frequently prescribed potentially inappropriate psychotropic drugs were amitriptyline and long-acting benzodiazepines such as diazepam, chlordiazepoxide, and flurazepam. Logistic regression analyses revealed that inappropriate prescribing of psychotropic drugs for elderly patients was associated with particular patient characteristics (visit due to an injury), drug characteristics (number of medications prescribed and the drug being an antidepressant or antianxiety agent), and physician characteristics (psychiatric specialty and location in the South or Northeast). The patterns of psychotropic prescribing found in the ambulatory setting raise concerns about the quality of care being received by elderly patients with psychiatric illnesses.

Objective: To determine the prescription and over-the-counter (OTC) psychotropic medication and social drug (alcohol and caffeine) use patterns of community-based elderly caregivers of patients with dementia and elderly noncaregivers., Design: Cross-sectional study design in which characteristics of psychotropic medication and social drug use were collected including the specific agent, frequency, dose, and reason for use., Setting: A rural, sparsely populated agricultural area in the midwest region of the US., Sample: Thirty elderly caregivers of patients with dementia were recruited through a public health agency and homemaker health aid service. Thirty elderly noncaregivers were recruited through the senior citizens center in a neighboring rural community. Data were collected by interview., Results: A significantly greater number of caregivers used OTC psychotropic agents (43%) than did noncaregivers (3%; p < 0.001). In all cases these agents were used for sleep. The combined number of caregivers using prescription and OTC psychotropic products (63%) also achieved statistical significance compared with the control group (10%; p < 0.001). Caffeine was used by all members of both groups and alcohol was consumed by eight caregivers and seven noncaregivers., Conclusions: A greater percentage of rural caregivers of patients with dementia in this study took psychotropic agents compared with the noncaregiver group. OTC products for sleep were the most frequently used agents.

Inappropriate use or insufficient monitoring of psychotropic agents can have deleterious effects in dementia patients. HCFA regulations serve as a useful guide to the appropriate use of psychotropic agents for dementia patients in the community. A sizeable portion of caregivers are not trained to correctly identify the adverse effects of psychotropic agents. Acting in an advisory role, the pharmacist is a key member of the patient management team.

Objective: To document the termination of nightmares brought about by an alteration in the ophthalmic administration of beta-blocking and cholinergic agents., Patient: A 75-year-old man residing in a long-term care facility experienced nightly nightmares of approximately one-year duration., Intervention: Other potential causes for the nightmares were eliminated. The administration of the ophthalmic agents was evaluated and the resident was then instructed to alter administration to include closure of his eyes for one or two minutes after administration., Outcome: Following the alteration in administration the nightmares were not present and have not reappeared in the ensuing year., Conclusions: Ophthalmic application of beta-blocking and cholinergic agents is used for the treatment of glaucoma and has been reported to cause a wide variety of central nervous system effects. Researchers have documented reduced systemic absorption and enhanced ocular retention time with specific modifications in the administration of the ophthalmic products. Based on this research the suggestion has been made that systemic adverse effects may be reduced by altering administration through use of lid closure and lacrimal occlusion. This case validates this hypothesis and provides strong evidence for the need to counsel all patients receiving ophthalmic agents on proper administration, including techniques to reduce absorption in order to avoid undesirable systemic effects.