Post on 04-Jul-2015
description
Evidence-Based Geriatric Pharmacotherapy: 2010
H. Edward Davidson, PharmD, MPHEastern Virginia Medical School
Insight Therapeutics, LLC
Vaccines
Varicella Zoster Infection
Primary Infection
(Chickenpox)
Latency Reactivation(Shingles)
Varicella ZosterDorsal
Ganglion
Varicella Zoster In US(Pre-Vaccine Era)
Primary Infection in the U.S.
4 million cases annually
95% of persons infected by age 15
145 deaths annually; adult rate
higher
12,000 hospitalizations
annually
Varicella Zoster In US(Post-Vaccine Era)
Primary Infection in the U.S.
~ 800,000 cases annually
81% of persons vaccinated
~ 1500 hospitalizations
annually
66 deaths annually
Risk Factors for “Shingles”
Stressful events– trauma, surgical procedures, X-ray, other
physical, emotional stress
Immune system alteration– HIV, malignancy– drugs - cytotoxic, corticosteroids
Age– age-related decline in cell mediated immunity
Reducing Incidence of “Shingles”
Exposure to children with primary varicella infection (“Chickenpox”)– Pediatricians have a reduced rate of zoster – Household exposure enhances cell mediated
immunity
Varicella vaccination of adults– Several small studies and one large study
(38, 500 patients) have shown reduced incidence of zoster
– Vaccine (Zostavax) approved by FDA in 2006
Number of Herpes Zoster Cases Observed in MSGP4
0
20
40
60
80
100
120
140
160
180
2000-
4
5-9
10-1
4
15-1
9
20-2
4
25-2
9
30-3
4
35-3
9
40-4
4
45-4
9
50-5
4
55-5
9
60-6
4
65-6
9
70-7
4
75-7
9
Age
Zo
ster
cas
es
Data – Children < 16 years
Data – No Children
Model – Children < 16 years
Model – No Children
Brisson, M et al. Vaccine. 2002MSGP4 = National Survey of Morbidity in General Practice 4
Prediction of Post-Vaccination Incidence of Herpes-Zoster
0
100
200
300
400
500
600
700
800
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
No Vaccination
Best Fit, 20yrs immunity
95% CI, 7-41yrs immunity
Zo
ster
inci
den
ce r
ate
(per
100
,000
per
yea
r)
Year after start of vaccination
Brisson, M et al. Vaccine. 2002
Herpes Zoster Related Hospitalizations and Expenditures Before and After
Introduction of the Varicella Vaccine in the
United States
Patel MS et al. Infect Control Hosp Epidemiol 2008;29:1157-63
Herpes-Zoster Related Hospitalizations
Retrospective analysis of a deidentified dataset, Nationwide Inpatient Sample (NIS) (AHRQ)
Nationally representative sample Study period 1993 – 2004 Herpes zoster-related hospital discharges
(HZHDs) and varicella-related hospital discharges (VRHDs) identified (ICD-9)
Resource utilization and clinical data analyzed
HZHDs and VRHDs by Year
Universal Universal Vaccination in U.S.Vaccination in U.S.
HZHDs by Year and Age
Universal Universal Vaccination in U.S.Vaccination in U.S.
Cost of HZHD and VRHD by Year
Universal Universal Vaccination in U.S.Vaccination in U.S.
Barriers to Use of Herpes Zoster Vaccine
Hurley LP et al. Ann Intern Med 2010;152;555-60. Mail + internet-based survey of general internists
and family medicine physicians, July-Sept 2008 Funded by CDC Measured survey responses on:
– Current vaccination practices– Knowledge and practice regarding reimbursement– Barriers to vaccination
Perceived Barriers to Administering HZ Vaccine in the Office
56191312Difficulty in obtaining vaccine
35302312More pressing medical issues
42222016Need to store in freezer
34182523Patient pick-up at pharmacy
19172143Up-front costs for practice
13102552Reimbursement issues
7103053Cost for patient
Not at allMinorSomewhatMajor
Responses, %
Barrier
Provider strength of recommendation for herpes zoster vaccine compared with other vaccines
Hurley L P et al. Ann Intern Med 2010;152:555-560
©2010 by American College of Physicians
Take away …
Less than 7% of target population (> 59 yrs, no recent hx) for HZ vaccine have received it1
Epidemiologic evidences suggest a “rash” of new cases in the elderly are coming
Barriers exist to HZ vaccine administration– Storage – refrigerator stable formulation licensed in
EU– Cost – covered by Medicare (under Part D); need to
streamline reimbursement process– Lack of awareness of epidemiology trend
1. Schiller JS, Euler GL. CDC, 2010.
Psychopharmacology
Snitz BE, O'Meara ES, Carlson MC, et al. Ginkgo biloba for preventing cognitive decline in older adults: a randomized trial. JAMA 2009;302:2663–2670.
DeKosky ST, Williamson JD, Fitzpatrick AL, et al. Ginkgo biloba for prevention of dementia. JAMA 2008; 300: 2253–2262.
Overview of GEMS
Primary outcome: Determine whether occurrence of dementia (any type) and Alzheimer’s disease specifically is lower for older people with normal memory treated with Ginkgo biloba compared with a placebo
Design:
– Randomized, double-blind, multi-center clinical trial
– 3,069 persons ≥ 75 years old with normal memory or very mild cognitive impairment (MCI = 10%)
Secondary Outcomes
All-cause mortality Combined CHD – nonfatal MI, CHD death,
coronary revascularization, hospitalized angina Combined CVD – combined CHD, stroke, lower
extremity revascularization, treated angina, fatal/ hospitalized/treated CHF, hospitalized or outpatient PAD
General cognitive function (change over time) Physical function
Sites in GEMS
5 clinical sites in the United States, all Academic Medical Centers:– Johns Hopkins (Hagerstown, MD)– University of California, Davis (Sacramento,
CA)– University of Pittsburgh, (Pittsburgh, PA)– Wake Forest University
o Winston-Salem, NCo Greensboro, NC
Randomized Design of GEMS
Persons with Normal Memory Function
or
Mild Cognitive Impairment (MCI)
Consent / Randomize
(3,069)
Ginkgo biloba
or
Placebo
Test every 6 months for:
2. New onset dementia of any type and Alzheimer’s disease specifically, and
3. Other outcomes until death or end of study (up to 6.5 years).
GEMS Results:Baseline Characteristics
Characteristic Placebo Ginkgo pa
N (%)/ Mean (SD) 1524 (50) 1545 (50) Age 79.1 (3.3) 79.1 (3.3) 0.88 Gender Females Males
716 (47) 808 (53)
702 (45) 843 (55)
0.39
Race Caucasian Non-Caucasian
1448 (95) 76 (5)
1482 (96) 63 (4)
0.23
Education High School or Less Some College College Graduate Post-Graduate
534 (35) 395 (26) 229 (15) 366 (24)
570 (37) 380 (25) 250 (16) 344 (22)
0.40
Medical History MI Heart Failure Stroke Hypertension Diabetes Cancer (past 5 yrs)
152 (10) 33 (2) 45 (3) 832 (55) 138 (9) 281 (18)
148 (10) 28 (2) 43 (3) 833 (54) 139 (9) 283 (18)
0.50 0.62 0.37 0.71 0.18 0.61
GEMS Results: Baseline Characteristics
Characteristic Placebo Ginkgo pa N (%)/ Mean (SD) 1524 (50) 1545 (50)
Cognitive Tests 3MSE (mean) CDR 0 0.5 ADAS-Cog
93.3 (4.7) 922 (61) 600 (39) 6.4 (2.7)
93.3 (4.7) 910 (59) 631 (41) 6.5 (2.8)
0.76 0.69
0.17 Difficulty with ADLs (1 or more) 269 (18) 273 (18) 0.99 Gait Speed (sec to walk 15 ft) 5.1 (1.5) 5.1 (1.2) 0.20 Mean Blood Pressure Systolic (mm/Hg) Diastolic (mm/Hg)
133(18.4) 69.0 (9.9)
133(18.1) 68.8 (9.9)
0.36 0.71
BMI Underweight (>18.5) Normal (18.5-25) Overweight (25-30) Obese (30+)
14 (1) 478 (31) 687 (45) 341 (22)
12 (1) 482 (31) 724 (47) 319 (21)
0.62
Smoking Status Never Former Current
622 (42) 805 (53) 65 (4)
602 (40) 846 (56) 71 (5)
0.51
Mild Cognitive Impairment at Baseline
226 (14.8)
256 (16.6)
.18
GEMS Results: Cumulative Dementia Rates by Treatment
GEMS ResultsHazard Ratios for Cox Regression Analyses All Dementia and Subtypes of Dementia comparing Ginkgo to placebo
Outcome All Participants
(N=3069)
# of
Events HR (95% CI)
P
value
All Dementia 523 1.12 (0.94, 1.33) 0.21
Alzheimer’s* without
vascular dementia** 353 1.18 (0.97, 1.46) 0.11
Alzheimer’s with
vascular dementia 124 1.09 (0.77, 1.55) 0.63
Total Alzheimer’s
Dementia 477 1.16 (0.97, 1.39) 0.11
Vascular dementia
without Alzheimer’s 24 0.41 (0.17, 0.98) 0.05
GEMS ResultsAdverse Events
Type of SAE Placebo
N (%)
Ginkgo
N (%)
Hazard Ratio
(95% C.I)
P
value
Deaths 188 (12.3) 197 (12.8) 1.04 (0.85-1.26) 0.72
Bleeding - total
GI
All Other
140 (9.2)
77 (5.1)
71 (4.7)
138 (8.9)
83 (5.4)
64 (4.1)
0.97 (0.77-1.23)
1.06 (0.78-1.45)
0.89 (0.64-1.25)
0.81
0.70
0.52
Myocardial Infarctions 76 (5.0) 90 (5.8) 1.18 (0.87-1.59) 0.30
Strokes
Ischemic
Hemorrhagic
Unknown
62 (4.1)
8 (0.5)
2 (0.1)
62 (4.0)
16 (1.0)
3 (0.2)
0.99 (0.70-1.41)
1.97 (0.84-4.61)
-
0.96
0.12
-
Overall Conclusion
Ginkgo biloba at 120 mg twice a day is not effective in reducing the overall incidence
of dementia or Alzheimer’s disease in older adults. Neither is Ginkgo biloba effective in preventing dementia in persons with
mild cognitive impairment.
GEMS Memory Study
A Case Study of Herbal RemedyPolypharmacy
77 yo wm referred to geriatric assessment clinic in CA spring 2009
Progressive problems with word finding, disorientation, agitation, and irritability
Sister with dementia History of smoking (quit 30 yrs ago), ethanol
abuse, illicit drug use Problem list (PCP); Alzheimer’s dementia
(MMSE 15/30, could not draw clock), CAD with history of MI, bradycardia, hypertension, dyslipidemia, gait and balance problems, hx falls, incontinence, depression
Prescription Medications
Pravastatin Lisinopril Aspirin Niacin Triamterene/hydrochlorothiazide Sertraline Donepezil Memantine
Dietary and Herbal Supplements
B-100 complex Coenzyme Q-10 Omega-3 fatty acids Core complex (quercetin) CardioHealth B-12 Folic Acid Vitamin C Vitamin E Beta carotene Valerian root complex
Vitamin D3 Calcium complex Triple berry complex Schizandra plus Mega garlic plus Garden 7 phytonutrients Rose OX Joint support Generic multivitamin Cell activator NiteWorks (amino acids)
Strategies to Address this Issue
Include discussion of supplements/herbal remedies with each medication reconciliation– Natural Medicines Comprehensive Database
(available from Prescriber’s Letter, www.naturaldatabase.com)
– On-line version also available
Research is limited on these products May be a waste of limited resources
Preferred Medications in the Elderly
Historically, medication use in the elderly has evolved around avoiding “potentially inappropriate medications” (e.g., Beers criteria)
Medicare Part D and PDPs have developed formularies based primarily on cost/rebates
Need for “geriatrics-focused expert review”
“Positive” Beers Criteria
First article published August 2009– Consult Pharm 2009;24:601-10.– http://
www.ascp.com/resources/clinical/upload/BeersCriteria.pdf
Focus on CNS medications Consensus panel of geriatricians, other
providers Literature review using AHRQ criteria for
comparative effectiveness Delphi consensus process on final selection
Definition: IOM
Comparative effectiveness research (CER) is the Comparative effectiveness research (CER) is the generation and synthesis of evidence that generation and synthesis of evidence that compares the benefits and harms of alternative compares the benefits and harms of alternative methods to prevent, diagnose, treat and monitor a methods to prevent, diagnose, treat and monitor a clinical condition or to improve the delivery of clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, care. The purpose of CER is to assist consumers, clinicians, purchasers and policy makers to make clinicians, purchasers and policy makers to make informed decisions that will improve health care at informed decisions that will improve health care at both the individual and population levels.both the individual and population levels.
National Priorities for Comparative Effectiveness ResearchNational Priorities for Comparative Effectiveness ResearchInstitute of Medicine Report BriefInstitute of Medicine Report Brief
June 2009June 2009
AHRQ’s Role in AHRQ’s Role in Comparative EffectivenessComparative Effectiveness
Using Information to Drive Improvement: Using Information to Drive Improvement: Scientific Infrastructure to Support ReformScientific Infrastructure to Support Reform
Lead federal fundingLead federal funding
Engage private sectorEngage private sectorAggregate best Aggregate best evidence to inform evidence to inform complex learning complex learning and implementation and implementation challengeschallenges
Increase knowledge base Increase knowledge base to spur high-value careto spur high-value care
21st Century Health Care
Comparative Effectiveness Comparative Effectiveness and the Recovery Act and the Recovery Act
The American Recovery and The American Recovery and Reinvestment Act of 2009 includes Reinvestment Act of 2009 includes $1.1 billion for comparative $1.1 billion for comparative effectiveness research:effectiveness research:
– AHRQ: $300 millionAHRQ: $300 million
– NIH: $400 million (appropriated to NIH: $400 million (appropriated to AHRQ and transferred to NIH)AHRQ and transferred to NIH)
– Office of the Secretary: $400 million Office of the Secretary: $400 million (allocated at the Secretary’s discretion)(allocated at the Secretary’s discretion)
Federal Coordinating Council appointed to coordinate comparative Federal Coordinating Council appointed to coordinate comparative effectiveness research across the federal governmenteffectiveness research across the federal government
Preferred CNS Medicationsfor the Elderly
Entacapone (add-on only)RopiniroleCarbidopa/Levodopa
Parkinson’s Disease
CitalopramDuloxetineEscitalopramBupropionMirtazapine
Depression
DonepezilGalantamine (ER only)Memantine (add-on only)
Dementia
MedicationTherapeutic Area
Take Away …
Comparative effectiveness is coming Research funded by American Recovery and
Reinvestment Act of 2009 will begin soon This is an example of how criteria might be
applied and the results NICE (National Institute for Clinical Evidence),
the European Union equivalent to proposed comparative effectiveness, provides an example of what we might expect in the future
http://www.nice.org.uk/
Chronic Kidney Disease
800
1000
1200
1400
1600
1800
2000
2200
Cre
atin
ine
Exc
reti
on
, m
g/d
ay
0.0
0.2
0.4
0.6
0.8
1.0
1.2
Ser
um
C
reat
inin
e C
on
c.,
mg
%
Average Age, years20 40 60 80
Creatinine Excretion and Serum Creatinine by Age
10 73 122 152 94 68 29
Equations for Estimating GFR
Abbreviated MDRD Study EquationAbbreviated MDRD Study Equation
GFR (mL/min/1.73 m2) = 186.3 × SCr -1.154 × Age-0.203
× 0.742 (if female) × 1.210 (if African American)
MDRD = Modification of Diet in Renal Disease; CrCl = creatinine clearance; SCr=serum creatinine in mg/dL
Cockcroft-Gault EquationCockcroft-Gault Equation
CrCl = (mL/min)
(140 – Age) × Weight in kg
72 × SCr× 0.85 if female
Levey AS, et al. Ann Intern Med. 2003;139:137-47.Levey AS, et al. Ann Intern Med. 2003;139:137-47.
0
20
40
60
80
65-69 70-74 75-79 80-84 85-89 90-94 95+
<30 (Men) <30 (Women) 30-59 (Men) 30-59 (Women)
Age (years)
Per
cen
t o
f P
atie
nts
Garg AX, et al. Kid Int 2004;65:649-53.Garg AX, et al. Kid Int 2004;65:649-53.
Prevalence of Low GFR in Nursing Home Elderly – Cockcroft-Gault
0
20
40
60
65-69 70-74 75-79 80-84 85-89 90-94 95+
<30 (Men) <30 (Women) 30-59 (Men) 30-59 (Women)
Age (years)
Per
cen
t o
f P
atie
nts
Garg AX, et al. Kid Inter 2004;65:649-53.Garg AX, et al. Kid Inter 2004;65:649-53.
Prevalence of Low GFR in Nursing Home Elderly – MDRD
Cockcroft-Gault (CG) or MDRD?
Recent Study in JAGS 2009;57:1638-43 Measured CrCl based on 24-hour urine
collection Comparison to measured value:
– CG slightly underestimates CrCl– MDRD strongly overestimates CrCl
KDOQI guidelines recommend MDRD for diagnosing and staging of CKD
CG should be used for dosing medications
KDOQI = Kidney Disease Outcomes Quality InitiativeKDOQI = Kidney Disease Outcomes Quality Initiative
Drugs That Need Special Attention in CKD
Warfarin– Warfarin metabolism not significantly altered– Hemorrhage more likely - probably due to platelet
dysfunction/drug-interactions
Low-molecular-weight heparins– Cleared primarily by the kidneys– Risk of hemorrhage more likely with CKD– Dose reduction required for most (usual cut-off 30 ml/min)
Direct thrombin inhibitors– Reduce dose for most – Hirudin, lepirudin– Fondaparinux – avoid when CrCl less than 30 ml/min
Gabardi S, Abramson S. Med Clin N Am 2005;89:649-87.Gabardi S, Abramson S. Med Clin N Am 2005;89:649-87.
Drugs That Need Special Attention in CKD (2)
ACE inhibitors– As a class, generally cleared by the kidney (exception
is fosinopril – hepatobiliary excretion)– Reduce dose, however use not contraindicated – ACEs beneficial in many with CKD (diabetes, CHF)– NSAIDs should be avoided with ACEs in CKD
ARBs– Metabolized by liver – no adjustment needed– Similar risk for ARF to ACE – monitor appropriately– Combination of ACE + ARB seems to be safe in CKD
Gabardi S, Abramson S. Med Clin N Am 2005;89:649-87.Gabardi S, Abramson S. Med Clin N Am 2005;89:649-87.
Drugs That Need Special Attention in CKD (3)
Antihypertensive agents– Alpha-blockers – increased risk of orthostasis/hypotension– Beta-blockers – increased risk of bradycardia: reduce dose of
acebutolol, atenolol, nadolol, and sotalol
Diuretics– Spironolactone + ACE in HF (↑ K+); careful in advanced CKD
(SCr ≥2.5; GFR <15 mL/min)– Thiazides have little effect if used alone in CKD – trouble
reaching the nephron– Loops have similar problems, but dose increases or the addition
of a thiazide may overcome resistance– Ototoxicity is more common in CKD due to impaired clearance
and higher doses of loops used
Gabardi S, Abramson S. Med Clin N Am 2005;89:649-87.Gabardi S, Abramson S. Med Clin N Am 2005;89:649-87.
Drugs That Need Special Attention in CKD (4)
NSAIDs; problems in CKD include hyperkalemia, hyponatremia, fluid retention, acute renal failure
Narcotics– Meperidine metabolism altered in CKD, resulting in
accumulation of normeperidine (metabolite); may cause seizures
– Morphine metabolites (morphine-3 and morphine-6-glucuronide) can accumulate in CKD causing prolonged sedation and respiratory depression
– Oxycodone concentrations about 50% higher in CKD
Gabardi S, Abramson S. Med Clin N Am 2005;89:649-87.Gabardi S, Abramson S. Med Clin N Am 2005;89:649-87.
Drugs That Need Special Attention in CKD (5)
Oral Hypoglycemics– Acetohexamide, chlorpropamide, glyburide, and tolazamide; all
have active metabolites that may accumulate causing prolonged hypoglycemia
– Metformin: increased risk of lactic acidosis in CKD
Antimicrobials– Aminoglycosides/vancomycin: use with caution and if using,
monitor serum concentrations closely– Cephalosporins/penicillins; most are renally eliminated: in most
cases, dose is reduced in lieu of interval; Efficacy in UTI may be reduced
– Fluoroquinolones; most are renally eliminated. Better in UTI than cephs/pens in CKD
Gabardi S, Abramson S. Med Clin N Am 2005;89:649-87.Gabardi S, Abramson S. Med Clin N Am 2005;89:649-87.
Transitions of Care
Transition of Care vs Transitional CareTransition of Care vs Transitional Care
The movement of patients from one practitioner or setting to another
Multiple levels– Within Settings
o Primary care Specialty care
– Between Settingso Hospital Home
– Across health stateso Curative care Palliative
care/Hospice
A set of actions ensuring the coordination and continuity of care as patients transfer between locations or levels of care
Includes:– Logistical arrangements– Education of the patient
and family– Coordination among the
health professionals involved in the transition
Coleman E, et al. J Am Geriatr Soc 2003;51:556-7.
Ineffective Transitions Ineffective Transitions Lead to Poor OutcomesLead to Poor Outcomes
Wrong treatment Delay in diagnosis Severe adverse events Patient complaints Increased healthcare costs Increased length of stay
Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf
Care Transitions 30 DaysCare Transitions 30 DaysFollowing Acute CareFollowing Acute Care
Hospital
Home64%
77%13%
11%
Nursing Facility
Hospital or TCU
16% 10%
74%
TCU = Transitional Care UnitColeman EA et al. Health Svcs Research 2004;37:1423-40
Predictors of Complicated Predictors of Complicated Care TransitionsCare Transitions
Heart disease Diabetes # of prior hospitalizations Visual impairment Medicaid recipient Prior stroke
Coleman EA et al. Health Svcs Research 2004;37:1423-40.
Incr
easi
ng
Ris
k
Medication Discrepancies: Hospital to SNFs Transitions
Tija et al. J Gen Intern Medicine 2009. Cross-sectional study of patients admitted to
SNF for subacute care (N=199, 2319 meds) Results:
– 21.3% of medication orders had a discrepancy– At least one discrepancy in 71.4% of patients– CV agents, opioid analgesics, neuropsychiatric
agents, hypoglycemics, antibiotics, and anticoagulants accounted for > 50% of all discrepancies
SNF=Skilled nursing facility
Models of CareModels of Care
Guided Care– http://www.guidedcare.org/
The Transitional Care Model (TCM)– http://www.transitionalcare.info/
The Care Transitions Intervention (CTI)– http://www.caretransitions.org/
Project RED– http://www.bu.edu/fammed/projectred/
Project REDProject RED
http://www.bu.edu/fammed/projectred/index.html
http://relationalagents.com/red_demo_4545.wmv
CTM-3
The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital.
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose for taking each of my medications.
http://www.caretransitions.org/documents/CTM3Specs0807.pdf
Snow V et al. J Gen Intern Med 2009;24:971-6.
““Ideal Transition Record”Ideal Transition Record”(ACP, SGIM, SHM, AGS, ACEP, (ACP, SGIM, SHM, AGS, ACEP,
and SAEM)and SAEM)1. Primary, secondary diagnoses and problems list2. Medication list (reconciliation) including OTC/other 3. Treatment and diagnostic plan 4. Clearly identifiable medical home/coordinating and
transferring MD/institution and contact information5. Prognosis and outcome goals 6. Test results (available and pending)7. Patient cognitive status8. Advance directives, power of attorney, consent9. Planned interventions, med equipment, wound care10. Emergency plan, contact information 11. Assessment of caregiver status
Medication List ToolkitMedication List Toolkit
www.patientsafety.org/page/109587/
H.R. 3590 and H.R. 4872
Community-based Care Transitions Program Demonstration project to evaluate integrated
care around hospitalization Independence at home demonstration program State option to provide health homes to
Medicaid enrollees with chronic conditions Community Health Teams to support the
Patient-Centered Medical Home CMS Innovation Center to test models of care
Working to Address the Issueswww.ntocc.org
Recent Practice Guidelines
American Geriatrics Society - Pharmacological Management of Persistent Pain in Older Persons
Infectious Disease Society of America/ Society for Healthcare Epidemiology of America – Clostridium difficile infection in adults: 2010 update
American Medical Directors Association – Transitions of Care in the Long-Term Care Continuum
Questions?