Date of Award

January 2015

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Mary Tinetti

Subject Area(s)

Medicine, Gerontology, Pharmacology

Abstract

The three-quarters of older adults with multiple chronic conditions are at risk of therapeutic competition - situations in which treatment for one condition may adversely affect a coexisting condition. Our objectives were to 1) determine the prevalence of potential therapeutic competition in community-living older adults; 2) determine the most common combinations of conditions and medications in which therapeutic competition occurs; and 3) compare the frequency of use of a medication in individuals with and without a competing condition.

We conducted a cross-sectional descriptive study of a representative sample of 5,815 community-living adults 65 years of age and older in the U.S., enrolled 2007-2009 in the Medicare Current Beneficiary Survey. The 14 most common chronic conditions treated with at least one medication were ascertained from Medicare claims. Medication classes recommended in national disease guidelines for these conditions and used by at least 2% of participants were identified from in-person interviews conducted 2008-2010. Criteria for potential therapeutic competition included: 1) well-acknowledged adverse medication effect; 2) mention in disease guidelines; or 3) report in a systematic review or two studies published since 2000. Outcomes included prevalence of situations of potential therapeutic competition and frequency of use of the medication in individuals with and without the competing condition.

Of 27 medication classes, 15 (55.5%) recommended for one study condition may adversely affect other study conditions. Among 91 possible pairs of study chronic conditions, 25 (27.5%) have at least one potential therapeutic competition. Among participants, 1,313 (22.6%) received at least one medication that may worsen a coexisting condition; 753 (13.0%) had multiple pairs of such competing conditions. For example, among 846 participants with hypertension and COPD, representing over 3.5 million older Americans, 16.2% used a nonselective beta-blocker that might exacerbate their COPD while 39.6% received a beta agonist that could worsen their hypertension. In only 7 of 37 cases (18.9%) of potential therapeutic competition were those with the competing condition less likely to receive the medication than those without the competing condition.

Over one fifth of older Americans receive medications that may adversely affect coexisting conditions. Determining clinical outcomes in these situations is a research and clinical priority. Effects on coexisting conditions should be considered when prescribing medications.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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