Search

Geriatric Nursing Volume 25 Number 4 Since publication of the last drug consult column on lipid-lowering drugs 3 years ago,1 2 new drugs are being used for dyslipidemia, and the evidence supporting the use of drugs for dyslipidemia is mounting. Of particular interest for nurses working with older adults is information from recent clinical trials with large numbers of older adults to address questions about upper age limits for the benefits of lipid-lowering drugs. A recent review of such clinical trials concluded that “the notion that drug interventions are of no value in older patients should be abandoned.”2 Thus, gerontologic nurses need to keep up to date on the latest evidence-based recommendations for treatment of dyslipidemia and on information about lipidlowering drugs for older adults. Dyslipidemia, defined as abnormal serum lipoprotein levels, is a risk factor for cardiovascular disease when lowdensity lipoprotein (LDL) cholesterol levels are high or high-density lipoprotein (HDL) cholesterol levels are low. In 2001, the National Cholesterol Education Program published the Adult Treatment Panel (ATP III) guidelines for identifying and treating dyslipidemia,3 and these recommendations have been widely used for 3 years. The ATP III paid particular attention to people aged 50 years and older and encouraged health care providers to consider a number of risk factors for people of any age when evaluating the need for interventions. In contrast to previous reports that determined risk based partially on the ratio between LDL and HDL cholesterol, the updated report recognizes that HDL cholesterol should be maintained above 60 mg/dL, and LDL cholesterol should be low regardless of any ratio. For example, the LDL goal for healthy people with no risk factors is

Geriatric Nursing Volume 25 Number 3 Nurses working with older adults are responsible for planning interventions that facilitate their adherence to appropriate medication regimens. Because of the increasingly high cost of prescription drugs for older adults, nurses often need to address financial limitations as a barrier to adhering to medication regimens. In December 2003, Congress passed legislation that will give all Medicare beneficiaries access to prescription discount cards beginning June 1, 2004, and to some prescription drug coverage beginning in 2006. The legislation is very complex, and older adults have been bombarded with information about a confusing array of prescription benefit discount plans. Gerontologic nurses and other health care practitioners need to be familiar with these plans because they must educate older adults and their families about the most cost-effective ways to obtain prescribed medications. It is important to know that the major provisions of the Medicare drug bill do not take effect until Jan 1, 2006, and details of this plan are still being developed. Some of the highlights of the bill that nurses need to know now are: • Although the new Medicare drug benefit plan will not be implemented until 2006, Medicare-endorsed discount cards will be effective between June 1, 2004, and Dec 31, 2005. • Enrollment in any plan is voluntary. • The new drug plans will be most beneficial to people who have low incomes or annual overall drug Guiding Older Adults Through the Maze of Medicare Prescription Drug Benefits

64 Geriatric Nursing Volume 24 Number 1 In keeping with the theme of this issue of Geriatric Nursing, this column presents an overview of research findings from 2002 related to drugs that have been approved or are in development for the treatment or prevention of dementia. The sidebar summarizes research highlights, which are categorized according to their impact on progress toward the goal of advancing drug therapies for dementia. Although 2002 was the first year since 1999 in which the Food and Drug Administration did not approve any new drugs for dementia, new and valuable information about cholinesterase inhibitors emerged from studies. Since the 1990s, clinical trials of cholinesterase inhibitors, the only drugs approved for treatment of Alzheimer disease (AD), have shown moderate improvement in cognitive, behavioral, and functional deficits associated with mild to moderate AD. Studies published during 2002 expanded our knowledge about differing and longer-term effects of three of the four approved drugs: tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl). No studies of tacrine, the first cholinesterase inhibitor, were published in 2002, and the more recently developed drugs have largely replaced it. Current studies are addressing the use of cholinesterase inhibitors in types of dementia other than AD (eg, vascular and Lewy body). Probably the most exciting area of research on drugs for dementia is the potential role of statins (HMGCoA reductase inhibitors), drugs already widely used for hyperlipidemia. Epidemiological studies indicate that statins may be effective in preventing and treating dementia, and additional studies are in progress to explore the potential of these drugs. Studies also are underway to explore the relationship between statin drugs and pathological processes that cause dementia. One theory is that statins decrease beta-amyloid by decreasing the cholesterol burden and improving endothelial function and microvascular flow.1 However, another study2 concluded that clinical doses of statins do not significantly affect beta-amyloid secretion, but other effects of these drugs may be responsible for protecting against dementia. Drug Consult

In the past several years, the Food and Drug Administration (FDA) has approved one new antidepressant, and the National Institutes of Health has initiated clinical trials to test the effectiveness of an herbal preparation for depression. This column will review the current information on the newest antidepressant, citalopram (Celexa), and recent trends in the treatment of geriatric depression. A second aspect of emotional pain in elders that this column will address is the use of antipsychotics for some dementia-associated behaviors. Recent guidelines for prescribing psychoactive drugs in the elderly continue to emphasize the value of newer antipsychotics, called atypical antipsychotics, that act on both dopamine and serotonin receptors in the brain. 2 Newer antipsychotics also have the advantage of fewer serious adverse effects than haloperidol and other drugs that have strong anticholinergic effects. This column will review the newest of the atypical antipsychotics, olanzapine (Zyprexa) and quetiapine (Seroquel), as well as summarize nursing responsibilities related to the administration of antipsychotic medications for dementia-associated behaviors.

sent, medications should be prescribed at an earlier stage. This report emphasizes the importance of lifestyle modification, either alone or in combination with medications, to prevent and manage hypertension. The recommended modifications include no smoking, regular aerobic exercise, weight reduction when appropriate, limited intake of alcohol and sodium, adequate intake of calcium, potassium, and magnesium, and reduced intake of dietary saturated fat and cholesterol. A myth that is dispelled in this report is that a BP reading of “100 plus your age” is acceptable—unless your age is 40 or younger. Another dispelled myth is that the diastolic BP is more significant than the systolic BP. In fact, the report recommends treatment of isolated systolic hypertension, defined as a systolic pressure of 160 mmHg or higher and a diastolic pressure of 90 mmHg or less. Another issue addressed in this report is the phenomenon of “white coat hypertension,” a condition in which the patient’s BP is elevated in a medical office but is normal at other times. Selfmeasurement is a valid approach to monitoring BP and identifying the presence of white coat hypertension. Self-monitoring devices should be caliAlthough nurses are not the health professionals who most commonly prescribe medications for people with hypertension, they are the health care professionals who assess blood pressures (BPs) most often and can provide a wealth of information about hypertension prevention and treatment. Previous “Drug Consult” columns have reviewed guidelines for hypertension management and education regarding cardiovascular disease risks. Table 1 in this column summarizes the most recent recommendations of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC). These recommendations can serve as a guideline for nurses to identify people who need medical evaluation for hypertension treatment and assess the effectiveness of hypertension medications that have been prescribed. This column also summarizes categories and examples of medications now being used to manage hypertension. The sixth and most recent report of the JNC differs from the previous reports by defining hypertension more narrowly and emphasizing the need to evaluate and treat hypertension in relation to other risk factors. That is, if no other cardiovascular risk factors are present, BP readings of up to 160/100 mmHg should be managed with lifestyle changes for up to 1 year before initiating medications. However, if additional risk factors are preUpdate on Hypertension Management

Relat ively few gerontologic nurses are directly involved with clinical drug trials, but most gerontologic nurses have opportunities to help older adults and their families make decisions about participating in such trials. For example, although people with Alzheimer's disease cannot be offered any drug that will reverse the disease process, they might be given an opportunity to participate in a clinical drug trial for: • A new drug being investigated for dementia (eg, physostigmine) • A drug that has been approved for another condition and is under investigation for treatment of dementia (eg, estrogen or ibuprofen) • A drug that has been approved for one type of dementia and is being investigated for another (eg, donepezi l for vascular dementia) • A drug being evaluated for treatment of dementia-related problems (eg, melatonin for sleep disturbances) In a previous column 1 I described the drug approval process in the United States. This column will focus on phase 2 and phase 3 trials because they involve people who have been diagnosed with the condition under investigation for drug t reatment . Specifically this column will address ethical and practical issues regarding clinical trials for drugs being developed for dementia because this condition is one of the most rapidly evolving areas of drug research and is particularly relevant to gerontologic nurses. Nurses can discuss benefits and drawbacks of participating in clinical drug trials with older adults and their families and can encourage them to contact the Alzheimer's Association (800-272-3900) for upto-date information on clinical drug trials for dementia. Nurses should keep in mind, however, that clinical drug trials are in progress for many conditions, and information can be obtained from such organizations as the American Cancer Society, the American Heart Association, and the Arthritis Foundation. Phase 2 trials evaluate the safety and efficacy of a drug in a control led study involving several hundred volunteers who have the targeted condition. During phase 2 studies, an investigational drug that has been found to be relatively safe in healthy volunteers is tested for the first time on people who have the condition. After phase 2 studies have been completed, volunteers are recrui ted for phase 3 studies, the purposes of which are to further evaluate the drug's safety and efficacy, including longterm results, and determine the optimal dosing regimen. These clinical trials usually last several years, involve several thousand volunteer patients, have strict criteria for part icipat ion and monitoring, and often exclude people who have medical conditions other than the targeted condition. Phase 2 and 3 studies typically are blinded, randomized, placebo-controlled, or dose comparison studies. Ideally, these studies are double blind, meaning neither the participants nor the investigators know which participants are receiving the drug being tested and which are receiving a placebo or another therapy. The assignment code is broken only after the study is completed to reveal

Care of diabetic patients used to be quite simple: patients with insulin-dependent diabetes mellitus, also called Type I diabetes, gave themselves insulin shots, followed an American Diabetic Association diet, and tested their urine for sugar and acetone. Patients with noninsulin-dependent diabetes mellitus, also called 'Type II diabetes, took a sulfonylurea drug and watched their diet. In the 1980s, glucometers enabled patients to monitor their blood glucose levels, so urine tests became pass& Several new generations of sulfonylureas also were introduced in the 1980s. By the mid-1990s, newer classes of antidiabetic agents became available, and one new type of insulin was approved by the Food and Drug Administration (FDA). Now diabetic patients commonly take combinations of two oral drugs, two types of insulin, or insulin and an oral drug. In addition to keeping up with new developments in antidiabetic drugs, nurses must keep up-to-date on a wide array of glucose monitoring systems. Nurses also must be aware of a variety of ways to deliver insulin, including new types of prefilled syringes and disposable needles. This column reviews the new developments in medications for diabetes and summarizes information about the oral antidiabetic agents in Table 1. Insulin, the primary treatment for patients with Type I diabetes, often is used as a second-ary treatment for pat!ents with Type II diabetes. Insulin is categorized as rapid-, intermediate-, or long-acting, and combinations of these types may be mixed together. Lispro (Humolog), approved by the FDA in mid-f996, is the first new type of insulin since the early 1980s. This type of insulin is absorbed more rapidly than regular insulin, reaches higher peak concentrations, and has a shorter duration of action. Because lispro insulin more closely imitates the action of natural human insulin, glucose levels are more stable. Although diabetics on regular insulin are instructed to inject the insulin half an hour before eating, diabetics using lispro insulin should inject it 15 rainutes or less before eating. Lispro insulin offers less risk of hypoglycemia and better control of postprandial hyperglycemia. Sulfonylurea hypoglycemic agents are divided into first-, second-, and third-generation drugs. Drawbacks include hypoglycemia and weight gain. Sulfonylureas usually are ini~. tiated as monotherapy but;i:'< may be combined with metformin or acarbose if ade-.~ quate diabetic control is not achieved or maintained. Glimepiride, a third-generation sulfonylurea, is the only sulfonylurea approved for use with insulin. Metformin, n e w deve/( in t roduced in 1995, is as effective as the sulfonylureas but is not likely to cause hypoglycemia or weight gain. This drug also may have a positive effect on up-to-I lipid levels by reducing cholesterol and triglycerides. Acarbose, approved by the FDA late in 1995, often is used i of glu( for people with postprandial hyperglycemia because it slows ,, ,,ii onitoring digestion of carbohydrates rather than affects the level of insulin in the body. This drug, usually prescribed to be taken 3 times daily with the first bite of each meat, may be used in combination with insulin or oral medications. Approved in 1997, troglitazone is the first in a new class of drugs that reduces insulin resistance. This drug is used for patients who do not achieve adequate diabetic control with insulin or an oral antidiabetic agent. Some patients may be able to reduce or eliminate the need for insulin when they use troglitazone. Potential advantages include decreased triglycerides and lower blood ntidiabetic drugs