SCCG News�SENIOR CARE CONSULTANT GROUP�

January 2007�

In this Issue:�·� Adverse Drug�

Events�·� Renal Impairment�·� Alzheimer’s Drugs�

Failing�·� Tropical Fruit Juices�·� Skin Tears in the�

Elderly�·� MedicationUpdate�·� Rumor vs. Truth�·� NutritionUpdate�·� CaregivingUpdate�·� Depression After�

Stroke�

Adverse Drug Events�

A�dverse drug events send elderly patients to the emergency department about as�often as car accidents. Over 700,000 patients are treated in emergency departments�each year for adverse drug events, or 2.4 out of every 1,000. And one in six of these are�hospitalized.�

The most common reactions are dermatologic, gastrointestinal and neurological. One-�third of events are due to allergies, another third are unintentional overdoses. The most�common culprits are insulins, opioids, anticoagulants, amoxicillin and antihistamines or�cold remedies.�

Almost one-third of adverse drug events in the elderly are caused by just three drugs:�warfarin, insulin and digoxin. And these drugs have been around for a long time. Keep in�mind that these numbers probably underestimate how often drug reactions present to�emergency departments.�

It is important to watch for appropriate doses. Up to half of adverse drug events may be�due to too much drug for the patient’s age, weight, renal function, or diseases. Patients�should stay on the look-out for significant drug interactions. As well as making sure they�are not doubling up by continuing a similar drug that is supposed to be discontinued or�changed. Close monitoring is recommended for patients on warfarin or insulin.�

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E�xperts are reminding us of the risk of renal impairment�in patients taking an ACE inhibitor or ARB, diuretic, and�NSAID. These drugs reduce renal perfusion by different�mechanisms. Combining any two of these drugs can lead�to acute renal failure in susceptible patients. Combining all�three is a “triple whammy.” These are patients who�already have impaired renal function or those at risk due�to older age, heart failure, dehydration, etc. Avoiding�chronic NSAIDs or aspirin for pain is recommended for�these patients. However, stopping low-dose aspirin is�NOT recommended; doses of 325 mg/day or less aren’t�likely to cause renal problems.�

Monitoring susceptible patients for worsening renal�function, increased blood pressure or potassium or edema�is recommended. Physicians do not need to reduce the�dose or stop an ACE inhibitor or ARB unless serum�creatinine increases more than 30% within 2 months of�starting the drug, or serum potassium exceeds 5.5 mEq/L.�

Consultant Pharmacists . . . Dispensing Knowledge�

M�ost Alzheimer’s patients will not benefit from�the drugs most commonly used to treat their�agitation and aggression, a new major has found.�The drugs, Zyprexa, Seroquel and Risperdal, are�no more effective than placebos, according to the�study published in�The�New England Journal of�Medicine.�

The drugs also put�patients at risk for�serious side effects. It is�the third major study to�find that the drugs,�known as atypical�antipsychotics, are not as�effective as they have�been portrayed.�

Antipsychotic Drugs Failing�Renal Impairment�

T�ropical fruit juices such as MonaVie, XanGo, Noni,�Gogi, and Pom Wonderful are making a big splash.�They’re promoted for everything from longevity to�infections and cancer. And the promotions are so�convincing that they sometimes can even make�pharmacists wonder if the claims are valid.�

These juices contain antioxidants. But this doesn’t�mean that they can be counted on to cure certain�diseases. And they often sell for over $40/bottle.�

Acai� (A-sigh-EE) is the main ingredient in MonaVie.�Acai is sometimes called a “superfood” because it�contains more antioxidants than blueberries or�cranberries. But there’s no proof that it’s more�beneficial than other foods.�

Mangosteen� is often called “Xango” juice. It is high in�antioxidants called xanthones.�

Mornida is also know as “Noni” juice. It MIGHT be�associated with a few cases of liver toxicity.�

Patients on ACEs, ARBs and�spironolactone should be warned�that morinda is high in potassium,�almost 15 mEq per 8 ounces.�

Goji contains sterols that prevent�cholesterol absorption, but there’s�no proof that drinking Goji helps lower cholesterol. To�be safe, patients on warfarin should stay away from�Goji as it might inhibit warfarin metabolism.�

Pomegranate juice (Pom Wonderful) has preliminary�evidence that it might have some cardiovascular�benefits. But there are concerns about possible drug�interactions, similar to grapefruit juice.�

People should remember that these are basically fruit�juices and okay to drink in modest amounts. But�despite the hype, there is no proof they cure any�disease, and people should not expect miracle cures.�

Tropical Fruit Juices Making a Big Splash�

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P�eople over 65 experience about 90% of all skin tears, according to a recent study of nearly 3,000 incident�reports in Pennsylvania.�

While most skin tears are not serious enough to extend a hospital stay, they represent painful and unsightly�injuries, according to an article published in the September issue of the�Patient Safety Advisory�. It examined a�stud of 2,807 reports submitted by healthcare facilities to the Pennsylvania Patient Safety Reporting System�(PA-PSRS).�

Reports submitted to PA-PSRS during the system’s first full 12 months of mandatory statewide reporting reflect�findings from previous studies, which show the risk of skin tears increasing with age. The largest proportion of�skin tear reports (41%) concern patients aged 75 to 84.�

Treating a skin tear is also time consuming and painful for the patient. One report highlighted in the article�describes a patient having to undergo stapling and stitches to treat a skin-tear wound. Also, if changing the�dressing for a skin tear is done incorrectly, further injury may occur.�

“The (state’s Patient Safety) Authority chose to highlight the skin tear issue because of the high number of�patients who experience these painful wounds, especially among older and more fragile populations,” said Alan�B.K. Rabinowitz, administrator of the Patient Safety Authority. “By providing clinical guidance about prevention�and treatment of skin tears, we hope that healthcare facilities and providers will better understand the additional�risks associated with skin tears and the number of ways these injuries can be prevented.”�

Some patients characteristics cited in the� Advisory� that often mean a patient’s skin is more fragile and�susceptible to tears include: advanced age (over age 70); malnourishment; vision/sensation/hearing loss; mental�impairment; and immobility.�

The article includes several preventive measures. The Authority also is supplying healthcare facilities with a�“Skin Tears Toolkit” to help them prevent injuries. For this and other information, visit the Authority’s Web site at�www.psa.state.pa.us.�

Older People More Prone to Skin Tears�

I�t turns out pot could be like, good for the brain. A main ingredient in marijuana, THC, appears�to slow the progression of Alzheimer’s disease, according to a research team at the Scripps�Research Institute in La Jolla, CA.�

A� new treatment involving monthly eye injections of an antibody may help prevent blindness�associated with “wet” age-related macular degeneration, according to studies in the� New England�Journal of Medicine.�

T�reating dementia with cholinesterase inhibitors, or ChE-IS, may help delay their placement into nursing�homes, according to a study in the journal,�Alzheimer’s Disease and Associated Disorders�. The drug is also�known as Aricept, Excelon and Razadyne.�

M�anufacturer prices for the most commonly prescribed drugs for people 50 and older increased by an�average of 6.3% during the 12-month period ending in June, according to a recently released AARP survey. The�rise out-paced inflation.�

O�lder patients experience a drug error rate nearly seven times greater than younger patients, according to an�analysis by Medco Health Solutions, a prescription drug manager. Patients over 65 faced the greatest risk of�errors.�

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Medication�Update�

Rumor vs. Truth�

R�umor: Vitamin D helps prevent some cancers.�

T�ruth: Vitamin D deficiency is associated with an increased risk of breast, colon,�prostate, pancreatic and ovarian cancer. Researchers think vitamin D might have�

antiproliferative effects in these cancers. Recent research seems to support this hypothesis. Higher vitamin D�serum levels seem to be associated with a reduced risk of cancer and cancer-related mortality in men. And�people with higher intakes of vitamin D appear to have a lower risk for pancreatic cancer.�

Patients should understand that this is interesting research, but it's too soon to say that taking vitamin D�supplements will prevent cancer. But it's another good reason to ensure that they get enough vitamin D through�dietary measures and sun exposure.�

The best source of vitamin D comes from the sun. Ultraviolet-B light stimulates vitamin D synthesis in the skin,�providing as much as 80% to 90% of the body's vitamin D stores. This is why vitamin D deficiency is most�common in the northern latitudes, including Canada and the northern US where people are exposed to less sun.�Prevalence of vitamin D deficiency is on the rise, possibly due to overzealous use of sunscreens.�

Patients need to be reassured that BRIEF periods of unprotected sun exposure is not harmful. And just 15�minutes of sun exposure 2 to 3 times a week, is probably enough to meet Vitamin D needs for fair-skinned�people. Darker-skinned people or those at more northern latitudes might need more. For longer exposure,�recommend use of a sunscreen with an SPF 15 or greater to protect the skin.�

Patients who have minimal exposure to the sun are advised to get at least 400 IU/day of vitamin D from diet or�supplements, while 800 IU/day for elderly patients is recommended to help prevent osteoporosis.�

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P�eople are asking about the benefits of green tea. Lots of green tea drinks are hitting�the market, plus a new population study suggests that green tea decreases mortality.�

Green tea is high in polyphenols, substances which act as free-radical scavengers and�antioxidants. So far, most of the attention has been on green tea. But black and oolong�tea also contain similar amounts of polyphenols. Polyphenols are also found in virgin�olive oil, chocolate, red wine, and other foods thought to have extra health benefits.�

Cardiovascular - Epidemiologic studies suggest that people who drink green tea have a�lower risk of hypertension and heart disease. Now an observational study from Japan�suggests that people who drink green tea are less likely to die of cardiovascular disease. But this is seen in people�who drink 3 to 5 cups/day or more, and it doesn’t prove that green tea is responsible for the benefit.�

Cancer - Numerous studies show an association between consuming green tea and a decrease in different types of�cancer. But patients should know that there’s no proof that green tea prevents cancer.�

Weight loss - A new green tea soft drink called�Enviga� is being introduced by Coca-Cola. They claim it helps burn�calories, about 20 to 33 calories per 12-ounce can.�Enviga� also contains 100 mg of caffeine, 3 times as much as�Coke�.�Green tea and caffeine can help boost metabolism. But people should not count on�Enviga� for significant weight loss.�

Diabetes - people who drink a lot of green tea or coffee seem to have a lower risk of developing type 2 diabetes. Coffee�also contains polyphenols, or the caffeine might play a role.�

It’s too soon to tell if tea has any long-term benefits. People should be advised not to get carried away and consume�too much caffeine.�

Nutrition�Update�

S�troke survivors, their families and their physicians should be on the�lookout for depression, even years after an incident occurs, a new study�suggests. Many long-term survivors suffer from this problem but few�actually receive treatment, according to a report in the journal�Stroke�.�

Investigators from the National Stroke Research Institute in Victoria,�Australia, identified depression in 17% of a group of 289 five-year�stroke survivors. Only 22% of that subgroup were taking an�antidepressant medication.�

Depression After Stroke�

Caregiving�Update�

F�lex those muscles, arthritis sufferers. That’s the advice from a new study that indicates strength training for the legs�may slow knee arthritis. Researchers found that older adults with knee osteoarthritis who underwent lower-body�strength training showed less narrowing in the knee joint space over more than two years, an indication that their�arthritis was progressing more slowly.�

S�eniors who received two small doses of behavioral therapy two weeks apart recorded notable improvement in�sleep-quality measurers, compared with peers who only received information on insomnia, researchers at the�University of Pittsburgh School of Medicine found. Nearly twice as many of those behavioral therapy study subjects�(71% to 39%) slept better and also noted significant improvement in daytime symptoms of depression and anxiety,�according to the study.�

T�he incidence of Alzheimer’s disease in older people who drank fruit or vegetable juices three or more times a week�was 76% lower than those who did not, a 10-year study showed. It was 16% lower in those who drank juice once or�twice a week, according to researchers at Vanderbilt University School of Medicine. Researchers attributed the positive�effect to polyphenols, a strong antioxidant found in the peel of skins of fruits and vegetables.�