New Treatments May Bring New Challenges for Older Adults

It is important for clinicians to stay up-to-date on the latest medicines and other advances in treatment. At the same time, caution must be used when considering the use of new products with older adults. This patient population is often not adequately represented in clinical trials, and the treatment of older adults poses a number of safety and practical challenges that must be considered. The articles in this issue of Annals of Long-Term Care: Clinical Care and Aging^® draw some much-needed attention to this important issue.

Insulin pens have been shown to reduce some of the barriers to effective insulin treatment, such as dosing errors and hypoglycemic events. Switching from insulin vials to insulin pens has also been shown to significantly reduce healthcare costs. Additionally, older adults may prefer to use insulin pens because of features that make them easier to use. The use of insulin pens does come with some safety concerns, however. For example, if one insulin pen is used on more than one patient, the patient’s biological matter can flow back through the needle into the insulin reservoir, presenting a risk of cross-contamination and transmission of blood-borne diseases. Additionally, effective safety pen needles must be selected in order to prevent needle sticks, which can become a source of disease transmission. There have been several reports of these medication administration errors occurring with insulin pens, although none to date in the long-term care (LTC) setting. John B. Hertig, PharmD, and Katelyn Brown, PharmD, conducted a survey of LTC health care professionals to elicit information about the prevalence and safety of insulin pen utilization in LTC settings. Risk mitigation strategies and best practices for insulin pen use were also solicited from respondents, with the goal of indentifying ways in which the safety of insulin pen use in older adults in LTC settings can be improved.

With the wave of new drugs being approved by the US Food and Drug Administration (FDA), clinicians are faced with the question of whether these drugs may benefit older adults in their care. Data from the clinical trials supporting these approvals may not be adequate to support the use of these drugs in older patients, because of the effect of aging on adverse events and pharmacokinetics and because older participants in the clinical trials necessary for drug approval are often healthier and younger than those who are prescribed medications in practice. Therefore, it is important to consider clinical trial data carefully before prescribing newly approved medications to older adults. Christine Eisenhower, PharmD, BCPS, and her colleagues reviewed the efficacy, safety, cost, and place in therapy for three drugs approved in 2014–2015. They caution that, although these drugs may be efficacious, this must be weighed against the potential risks of these drugs for older patients.

Vaccination against herpes zoster, or shingles—which arises when the varicella zoster virus, or chickenpox, reactivates after years of lying dormant—is the single most important strategy for the prevention of complications related to herpes zoster. For this reason, the Centers for Disease Control and Prevention recommends immunization of adults older than 60 years of age. The long-term effectiveness of the herpes zoster vaccination has been questioned, however, and shingles has occurred in some patients who received the vaccine. When shingles occurs despite vaccination, the extent of the rash and the severity of the neuropathic pain may be less. Although this suppression of the virus may benefit the patient, ironically, it can also confound the diagnosis. Iris Tio-Matos, MD, and Susan Cummings, ARNP, discuss the case of an 89-year-old woman with zoster sine herpete presenting with severe pain in a dermatomal distribution but not the appearance of a painful herpetiform rash. The authors caution that, for patients who present with severe pain and allodynia or with a more limited rash and less pain, atypical shingles should be considered in the differential diagnosis.