Geriatric pharmacotherapy represents one of the biggest achievements of modern medical interventions. However, geriatric pharmacotherapy is a complex process that encompasses not only drug prescribing but also age-appropriate drug development and manufacturing, appropriate drug testing in clinical trials, rational and safe prescribing, reliable administration and assessment of drug effects, including adherence measurement and age-appropriate outcomes monitoring. During this complex process, errors can occur at any stage, and intervention strategies to improve geriatric pharmacotherapy are targeted at improving the regulatory processes of drug testing, reducing inappropriate prescribing, preventing beneficial drug underuse and use of potentially harmful drugs, and preventing adverse drug interactions. The aim of this review is to provide an update on selected recent developments in geriatric pharmacotherapy, including age discrimination in drug trials, a new healthcare professional qualification and shared competence in geriatric drug therapy, the usefulness of information and communication technologies, and pharmacogenetics. We also review optimizing strategies aimed at medication adherence focusing on complex elderly patients. Among the current information technologies, there is sufficient evidence that computerized decision-making support systems are modestly but significantly effective in reducing inappropriate prescribing and adverse drug events across healthcare settings. The majority of interventions target physicians, for whom the scientific concept of appropriate prescribing and the acceptability of the alert system used play crucial roles in the intervention's success. For prescribing optimization, results of educational intervention strategies were inconsistent. The more promising strategies involved pharmacists or multidisciplinary teams including geriatric medicine services. However, methodological weaknesses including population and intervention heterogeneity do not allow for comprehensive meta-analyses to determine the clinical value of individual approaches. In relation to drug adherence, a recent meta-analysis of 33 randomized clinical trials in older patients found behavioural interventions had significant effects, and these interventions were more effective than educational interventions. For patients with multiple conditions and polypharmacy, successful interventions included structured medication review, medication regimen simplification, administration aids and medication reminders, but no firm conclusion in favour of any particular intervention could be made. Interventions to optimize geriatric pharmacotherapy focused most commonly on pharmacological outcomes (drug appropriateness, adverse drug events, adherence), providing only limited information about clinical outcomes in terms of health status, morbidity, functionality and overall healthcare costs. Little attention was given to psychosocial and behavioural aspects of pharmacotherapy. There is sufficient potential for improvements in geriatric pharmacotherapy in terms of drug safety and effectiveness. However, just as we require evidence-based, age-specific, pharmacological information for efficient clinical decision making, we need solid evidence for strategies that consistently improve the quality of pharmacological treatments at the health system level to shape 'age-attuned' health and drug policy.
- MeSH
- adherence k farmakoterapii statistika a číselné údaje MeSH
- farmakoterapie metody normy statistika a číselné údaje MeSH
- geriatrie metody normy statistika a číselné údaje MeSH
- lékové předpisy statistika a číselné údaje MeSH
- lidé MeSH
- medicína založená na důkazech metody normy MeSH
- nežádoucí účinky léčiv MeSH
- samoléčba statistika a číselné údaje MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
BACKGROUND: In practical sleep medicine, therapists face the question of whether or not to discontinue the ongoing use of hypnotics in patients, as well as the possible effects of discontinuation. The aim of this study was to evaluate the effects of discontinuing third-generation hypnotics on the results of cognitive-behavioural therapy (CBT) for primary insomnia in patients after long-term abuse. METHODS: Twenty-eight outpatients were treated by CBT for 8 weeks. The treatment outcome was estimated by means of differences among subjective clinical scales and polysomnography variables assessed before and after the treatment period. The therapeutic effect in a subgroup of 15 patients who had previously received hypnotics and were successively withdrawn during weeks 2-6 was compared to the effect achieved in patients who had not used hypnotics before CBT. RESULTS: There were no significant differences in baseline subjective and objective sleep characteristics between the hypnotic abusers and non-abusers. According to clinical scales and most polysomnographic measures, CBT was highly effective in both groups of subjects; it produced the greatest changes in total sleep time, REM sleep and sleep efficiency. Unexpectedly, discontinuation of hypnotics, as a factor in the analysis, was followed by an additional improvement of sleep efficiency and wake after sleep onset parameters. CONCLUSION: Our study confirmed the efficacy of CBT in both hypnotic-abusing and non-abusing patients with chronic insomnia. The results of this study suggest that tapered withdrawal of third-generation hypnotics during CBT therapy for chronic insomnia could be associated with improvement rather than worsening of sleep continuity.
- MeSH
- dospělí MeSH
- farmakoterapie statistika a číselné údaje MeSH
- hypnotika a sedativa terapeutické užití MeSH
- kognitivně behaviorální terapie metody MeSH
- lidé středního věku MeSH
- lidé MeSH
- nenasazení léčby statistika a číselné údaje MeSH
- polysomnografie MeSH
- poruchy iniciace a udržování spánku diagnóza farmakoterapie terapie MeSH
- senioři MeSH
- spánek REM fyziologie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- Názvy látek
- hypnotika a sedativa MeSH
OBJECTIVE: Authors investigated, cross-nationally, the factors, including demographic, psychiatric (including cognitive), physical, and behavioral, determining whether older people take their prescribed medication. Older adults are prescribed more medication than any other group, and poor adherence is a common reason for non-response to medication. METHODS: Researchers interviewed 3,881 people over age 65 who receive home care services in 11 countries, administering a structured interview in participants' homes. The main outcome measure was the percentage of participants not adherent to medication. RESULTS: In all, 12.5% of people (N=456) reported that they were not fully adherent to medication. Non-adherence was predicted by problem drinking (OR=3.6), not having a doctor review their medication (OR=3.3), greater cognitive impairment (OR=1.4 for every one-point increase in impairment), good physical health (OR=1.2), resisting care (OR=2.1), being unmarried (OR=2.3), and living in the Czech Republic (OR=4.7) or Germany (OR=1.4). CONCLUSION: People who screen positive for problem drinking and who have dementia (often undiagnosed) are less likely to adhere to medication. Therefore, doctors should consider dementia and problem drinking when prescribing for older adults. Interventions to improve adherence in older adults might be more effective if targeted at these groups. It is possible that medication-review enhances adherence by improving the doctor-patient relationship or by emphasizing the need for medications.
- MeSH
- adherence pacienta statistika a číselné údaje MeSH
- demografie MeSH
- farmakoterapie statistika a číselné údaje MeSH
- lidé MeSH
- logistické modely MeSH
- průřezové studie MeSH
- senioři MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- práce podpořená grantem MeSH
- srovnávací studie MeSH
- Geografické názvy
- Anglie epidemiologie MeSH
- Česká republika epidemiologie MeSH
- Francie epidemiologie MeSH
- Itálie epidemiologie MeSH
- Německo epidemiologie MeSH
- Nizozemsko epidemiologie MeSH
- Skandinávie a severské státy epidemiologie MeSH
- MeSH
- automatizace * MeSH
- chorobopisy * MeSH
- ekonomika nemocniční * MeSH
- farmakoterapie statistika a číselné údaje MeSH
- nemocniční lékárny * MeSH
- poplatky a výdaje MeSH
- spotřeba léčiv MeSH
- Publikační typ
- časopisecké články MeSH
- Geografické názvy
- Československo MeSH
