Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative by Fick et al was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older either because they are ineffective or because they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions. This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. This study is an important update of previously established criteria that have been widely used and cited.
The COACH Program was developed to assist patients with coronary heart disease in achieving coronary risk factor goals that have been recommended by evidence-based guidelines. A multicenter randomized controlled trial assigned 398 patients to usual care plus The COACH Program and 394 to usual care alone. The reduction in total cholesterol level from baseline to 6 months after randomization was 14 mg/dL (0.36 mmol/L) (95% confidence interval, 8-20 mg/dL [0.20-0.52 mmol/L]) greater in The COACH Program group than in the usual care group. Coaching produced substantial improvements in most of the other coronary risk factors and in patients' quality of life.
Debate continues about whether air travel predisposes to pulmonary embolism. Pérez-Rodríguez et al have assessed the incidence of symptomatic pulmonary thromboembolism (PTE) in passengers on long-haul flights arriving at Madrid-Barajas Airport, Madrid, Spain. The overall incidence of PTE was 0.39 per million passengers. On flights that lasted longer than 8 hours, the incidence was significantly higher than on flights that lasted between 6 and 8 hours (1.65 per 1 million passengers vs 0.25 per 1 million passengers; P<.001). The authors conclude that air travel is a risk factor for PTE and that the incidence increases with the duration of the travel.
This report by Cantor et al addresses the difficult situation in which a patient or surrogate decision maker wishes cardiopulmonary resuscitation to be attempted even though the physician believes that resuscitation efforts would be futile. It also reviews current controversies surrounding the subject of do-not-resuscitate orders and medical futility; discusses the complex medical, legal, and ethical considerations involved; and then offers recommendations as a guide to clinicians and ethics committees in resolving these difficult issues. As Cantor et al examine these issues, they focus on the Veterans Health Administration.
Nearly 20% of older adults are at high risk of heart disease and stroke from untreated isolated systolic hypertension (ISH). Long-term follow-up of the Pittsburgh cohort of the Systolic Hypertension in the Elderly Program (SHEP) revealed cardiovascular event rate estimates of 58% and 79% for the active and placebo groups, respectively (P = .001). Compared with normotensive controls, the relative risk of an event was 1.6 (95% confidence interval, 1.1-2.4) for ISH participants assigned to active treatment and 3.0 (95% confidence interval, 2.1-4.4) for the placebo group. Treatment of ISH in older adults results in reduced long-term (14 years) event rates. The authors conclude that treatment before advanced atherosclerosis develops will likely produce the best long-term outcome.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2003;163(22):2669. doi:10.1001/archinte.163.22.2669