Welcome to the inaugural issue of the new clinical newsletter of the ASCP Foundation. This newsletter is designed to highlight significant clinical developments and resources to assist health professionals involved in medication use by older adults. We hope that you find this newsletter to be a valuable resource, and we welcome your feedback in our ongoing efforts to improve the value of this publication.

Several significant journal articles were published in 2007 that have the potential to improve geriatric drug therapy. The articles described below are broad-based articles rather than articles focused on specific diseases.

Update to the ACOVE Indicators

The Assessing Care of Vulnerable Elders (ACOVE) project has been coordinated by Rand Corporation, with funding from Pfizer. The original set of ACOVE quality indicators was published in a supplement to Annals of Internal Medicine in 2001. An interim update was made later on, but now a comprehensive update has been made to the ACOVE indicators, with 392 quality indicators covering 14 different types of care processes. Twenty-five percent of the ACOVE indicators address medication use, including one entire chapter specifically on medication use in vulnerable elders. Other chapters address other clinical conditions and geriatric syndromes common in the frail elderly.

The updated ACOVE indicators are published in a supplement to the October 2007 issue of the Journal of the American Geriatrics Society. This supplement is available online free to non-subscribers. The most directly relevant article from this supplement is: Shrank WH, Polinski JM, Avorn J, Quality indicators for medication use in vulnerable elders. 
J Am Geriatr Soc 2007;55(s2):S373-82.

To view the table of contents for the supplement visit http://www.blackwell-synergy.com/toc/jgs/55/s2.

Drug Burden Index

Hilmer and colleagues have created a drug burden index to define the functional burden of medications in older people. Medications with anticholinergic or sedative properties were found to be sources of impairment of cognition and mobility in older adults age 70-79. Medication impact was related to dose and number of medications in a linear fashion. Total number of medications was not an independent risk factor for functional impairment when medications with anticholinergic or sedative properties were considered. This article provides a foundation for further research and possible development of prescribing software modules that may assist in prevention of adverse effects from use of multiple medications in older adults.

Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med 2007;167:781-7.
http://tinyurl.com/yt24px

Bridges to Health Model

Joanne Lynn, a geriatrician who is now director of the Office of Clinical Standards and Quality at the Centers for Medicare and Medicaid Services, is the lead author of an article in the Milbank Quarterly that presents a new framework for understanding health care delivery through population segmentation. Although the article does not specifically address drug therapy issues, the major contribution is highlighting the six million individuals with "long term frailty" as a distinct population segment with unique health care needs.

The article divides the population into eight groups, each with its own definition of optimal health and priorities among services. These population-focused priorities are interpreted in the context of the Institute of Medicine's six goals of quality—safe, effective, efficient, patient centered (i.e., meets the patient's desires and preferences within the care delivery environment), timely, and equitable—to yield a framework that could shape planning for resources, care arrangements, and service delivery. This article serves as a foundation for further research and discussion about health care delivery in the United States, and this has the potential for great impact on delivery of health services and medication prescribing for the frail elderly.

Lynn J, Straube BM, Bell KM, et al. Using population segmentation to provide better health care for all: the "Bridges to Health" model. The Milbank Quarterly, 2007;85:185-208.
http://www.milbank.org/quarterly/8502feat.html

Emergency Department Visits for ADEs in Older Adults

Budnitz and colleagues published a follow-up to a previous study in the Journal of the American Medical Association about emergency room visits related to adverse drug events. The previous study is available at http://tinyurl.com/2359ph.

The current study reports that three medications accounted for one third of emergency department visits for adverse drug events in older adults. Warfarin (17.3%), insulin (13.0%), and digoxin (3.2%) were the top three. By contrast, the combined list of medications considered potentially inappropriate according to the Beers criteria resulted in only 3.6% of emergency department visits. Considering frequency of prescribing, the risk of emergency department visits from warfarin, insulin, and digoxin is 35 times greater than the risk of visits from Beers criteria medications. Improvements in the prescribing and monitoring of these three medications have great potential to reduce the toll of adverse drug events in older adults.

Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 2007;147:755-65.
http://www.annals.org/cgi/content/abstract/147/11/755

Geriatric Conditions and Disability

This is the first major study to address the prevalence of geriatric conditions (or syndromes) in older adults and their association with disability. The study found that half of adults age 65 and older have one or more geriatric conditions. Geriatric conditions are similar in prevalence to chronic diseases in older adults and in some cases are as strongly associated with disability. The findings suggest that geriatric conditions, although not a target of current models of health care, are important to the health and function of older adults and should be addressed in their care. Perhaps this study will increase the visibility and attention focused on geriatric conditions, including the potential impact of drug therapy on causing or contributing to these conditions.

Cigolle CT, Langa KM, Kabeto MU et al. Geriatric conditions and disability: the health and retirement study. Ann Intern Med 2007;147:156-64.
http://tinyurl.com/258wpl

Insomnia among older adults is a hot topic right now, with a number of pertinent journal articles having been published recently. There is increasing recognition that aging, per se, does not result in increasing sleep complaints.

1. In the November 2007 issue of the Journal of the American Geriatrics Society, Fragoso and Gill provide a masterly, comprehensive overview of the causes of sleep disorders in older adults, emphasizing the multifactorial origin of most sleep disturbances in this population. They argue that, because of its multifactorial origins, sleep disruption can be conceptualized as a geriatric syndrome.

Fragoso CA, Gill TM. Sleep complaints in community-living older persons: a multifactorial geriatric syndrome. J Am Geriatr Soc 2007;55:1853-66.
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2007.01399.x

Vitiello MV. Growing old should not mean sleeping poorly: recognizing and properly treating sleep disorders in older adults. 
J Am Geriatr Soc 2007;55(11): 1882-3.
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2007.01401.x

2. The current issue of Clinics in Geriatric Medicine (February 2008) is a theme issue on the topic of Sleep in Elderly Adults. It has a variety of very useful articles. This issue can be accessed at http://geriatric.theclinics.com/.

3. The Institute of Medicine (IOM) of the National Academies released a report in 2006 entitled "Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem."

Institute of Medicine of the National Academies. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: National Academies Press, 2006.
http://www.iom.edu/CMS/3740/23160/33668.aspx

4. Hypnotics may be protective in preventing falls in older adults with insomnia, according to a study of more than 34,000 nursing home residents with an average age of 84 years. The patients with untreated insomnia were 30% more likely to fall, compared with those who were treated with hypnotics. But treating insomnia had no measurable effect on the patients' risk for hip fractures, according to the author.

Avidan AY, Fries BE, James ML, et al. Insomnia and hypnotic use, recorded in the Minimum Data Set, as predictors of falls and hip fractures in Michigan nursing homes. J Am Geriatr Soc 2005;53:955-62.
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2005.53304.x

ASCP Foundation Director of Clinical Affairs Tom Clark has established a new blog on issues in geriatric pharmacotherapy. The blog is periodically updated with new developments or alerts to significant new journal articles. To view the blog, visit http://web.mac.com/tclark31/Site/Blog/Blog.html.