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Biomedical subjects

R M Leipzig

Publications and source records attributed to R M Leipzig.

11 recordsLinked to original sources
PubMed1999

Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs.

OBJECTIVES: To evaluate critically the evidence linking psychotropic drugs with falls in older people. DESIGN: Fixed-effects meta-analysis. DATA SOURCES: English-language articles in MEDLINE (1966 - March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers. STUDY SELECTION: Systematic evaluation of sedative/hypnotic, antidepressant, or neuroleptic use with falling in people aged 60 and older. DATA EXTRACTION: Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and non-fallers taking specific classes of psychotropic drugs. RESULTS: Forty studies, none randomized controlled trials, met eligibility criteria. For one or more falls, the pooled odds ratio (95% confidence interval) was 1.73 (95%CI, 1.52-1.97) for any psychotropic use; 1.50 (95%CI, 1.25-1.79) for neuroleptic use; 1.54 (95%CI, 1.40-1.70) for sedative/hypnotic use; 1.66 (95%CI, 1.4-1.95) for any antidepressant use (mainly TCAs); 1.51 (95%CI, 1.14-2.00) for only TCA use; and 1.48 (95%CI, 1.23-1.77) for benzodiazepine use, with no difference between short and long acting benzodiazepines. For neuroleptics in psychiatric inpatients, the pooled OR was 0.41 (95%CI, 0.21-.82); for all other patients, the pooled OR was 1.66 (95%CI, 1.38-2.00). Comparing > or =1 with > or = 2 falls, mean subject age <75 versus > or =75 years old, communities with <35% versus > or =35% fallers, or subject place of residence did not affect the pooled OR. Increased falls occurred in patients taking more than one psychotropic drug. CONCLUSION: There is a small, but consistent, association between the use of most classes of psychotropic drugs and falls. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. The incidence of falls and their consequences in this population necessitate that future large randomized controlled trials of any medication in older persons should measure falls prospectively as an adverse outcome event.

Accidental Falls↗
PubMed1999

Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs.

OBJECTIVES: To evaluate critically the evidence linking specific classes of cardiac and analgesic drugs to falls in older people. DESIGN: Fixed-effects meta-analysis. DATA SOURCES: English-language articles in MEDLINE (1966 - March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers. STUDY SELECTION: Systematic evaluation of cardiac or analgesic drug use and any fall in people aged 60 years and older. DATA EXTRACTION: Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and nonfallers taking specific classes of cardiac and analgesic drugs. RESULTS: Twenty nine studies met inclusion criteria. None were randomized controlled trials. For one or more falls, the pooled Odds Ratio (95% Confidence Interval) was 1.08 (1.02-1.16) for diuretic use, 1.06 (0.97-1.16) for thiazide diuretics, 0.90 (0.73-1.12) for loop diuretics, 0.93 (0.77-1.11) for beta-blockers, 1.16 (0.87-1.55) for centrally acting antihypertensives, 1.20 (0.92-1.58) for ACE inhibitors, 0.94 (0.77-1.14) for calcium channel blockers, 1.13 (0.95-1.36) for nitrates, 1.59 (1.02-2.48) for type Ia antiarrhythmics, and 1.22 (1.05-1.42) for digoxin use. For analgesic drugs, the pooled OR was 0.97 (0.78-1.20) for narcotic use, 1.09 (0.88-1.34) for nonnarcotic analgesic use, 1.16 (0.97-1.38) for NSAID use, and 1.12 (0.80-1.57) for aspirin use. There was no statistically significant heterogeneity of pooled odds ratios. There were no differences between the pooled odds ratios for studies with mean subject age <75 versus > or =75 years old or for studies in communities with <35% versus > or =35% fallers. In studies of the relationship between psychotropic, cardiac, or analgesic drugs and falls, subjects reporting the use of more than three or four medications of any type were at increased risk of recurrent falls. CONCLUSION: Digoxin, type IA antiarrhythmic, and diuretic use are associated weakly with falls in older adults. No association was found for the other classes of cardiac or analgesic drugs examined. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. Older adults taking more than three or four medications were at increased risk of recurrent falls. As a result of the incidence of falls and their consequences in this population, programs designed to decrease medication use should be evaluated for their impact on fall rates.

Accidental Falls↗
PubMed1998

That was the year that was: an evidence-based clinical geriatrics update.

BACKGROUND: Physicians are faced with an ever-growing information base in medical practice. Studies regularly show a disparity between science and patient care, with scientifically validated practices often taking 20 years and more to enter mainstream clinical practice. OBJECTIVES: To review the recent medical literature for high quality studies that practicing geriatricians should be aware of, either because they provide evidence that might lead to a change in clinical practice or because they provide insight into common geriatric syndromes. DESIGN: Overview. DATA SOURCES: All articles abstracted or noted in ACP Journal Club, Evidence-Based Medicine, or The New York Times from July 1996 to June 1997. STUDY SELECTION: Studies that met the standards for inclusion in ACP Journal Club. STUDY DESIGN: Sampling plan (including eligibility criteria), sample size, response rate, data analysis plan, proportion available for follow-up, main outcomes and measures, main results. RESULTS: Review of the 98 articles that met criteria resulted in the identification of several themes of importance to geriatricians, including the hazards of hospitalization, the prevention of NSAID-induced peptic ulcers, and the treatment and prevention of Alzheimer's disease. The results of these studies expand the therapeutic armamentarium of practicing geriatricians, provide new insights into geriatric syndromes, and raise cautions about the use of certain therapies in older adults. CONCLUSIONS: Many methodologically rigorous studies relevant to the medical care of older people have recently been published. Evidence-based medicine and the use of journals of secondary publication are useful tools to enhance the efficiency of journal reading for geriatric practitioners whose interests span the journals of several disciplines and subspecialties.

Aged↗
PubMed1997

Fellowship training.

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Fellowships and Scholarships↗
PubMed1990

Psychopharmacology in patients with hepatic and gastrointestinal disease.

Psychotropic drugs often need to be prescribed to patients who also have pre-existing gastrointestinal (GI) and/or hepatic disease. This paper addresses the effect of GI and hepatic disease on the pharmacokinetics of psychotropic drugs, the effect of psychotropic drugs on pre-existing GI and hepatic diseases, the adverse GI and hepatic effects of psychotropic medications, the effects of GI medications on mental status, and the potential drug interactions between commonly prescribed GI medications and psychotropic drugs. Drug selection and dosage modification based on these considerations should allow safe and effective psychotropic treatment for patients with pre-existing GI and/or hepatic disease.

Gastrointestinal Diseases↗
PubMed1990

Rapid bedside assessment of postoperative confusion in older patients.

As the number of elderly patients undergoing surgery increases, postoperative confusion becomes an increasingly encountered problem. Postoperative confusion has long been recognized as a specific entity, but the etiology and risk factors have not been well defined. To make the diagnosis promptly, the physician must maintain a high index of suspicion. This review provides a series of brief mental status tests that can be administered quickly at the bedside and outlines a specific approach to treatment.

Activities of Daily Living↗
PubMed1988

Hydromorphone levels and pain control in patients with severe chronic pain.

To better understand the use of narcotic analgesics, the hydromorphone concentration was measured in serum samples from 43 patients with chronic severe pain who were receiving this drug. At the time of blood sampling, pain intensity, mood, and cognitive performance were assessed. There was large individual variation in the dose-drug level relationship. Seven patients with bone or soft tissue pain and drug levels of greater than or equal to 4 ng/ml had good pain control, whereas 10 did not. None of 15 patients with levels less than 4 ng/ml had pain control, despite drug doses similar to those given patients with higher levels. Thus 60% of the patients without control of their pain had hydromorphone levels below the lowest level that produced pain control. No patient with pain from nerve infiltration or compression had good pain control, irrespective of the drug level or dose. Poor mood correlated with high pain intensity and low drug level. Impaired cognitive performance was not related to drug level. Knowing that there is a low concentration of narcotic in the blood of a patient with chronic severe pain who is receiving high drug doses and who shows lack of both efficacy and side effects may reassure health care professionals that further narcotic dosage escalation is appropriate.

Adult↗
PubMed1987

Reversible, narcotic-associated mental status impairment in patients with metastatic cancer.

Pain and mental status were assessed in a series of 35 consecutive hospitalized patients with metastatic cancer receiving narcotics for pain that was difficult to control. Forty-five episodes of mental status impairment were detected in 27 of these patients. Fifteen patients had dose-related oversedation or organic brain syndrome. In only 4 could the narcotic dose be decreased without exacerbating the pain. Eleven patients had mental status impairment associated with factors other than the narcotic dose. These factors were: concurrent CNS-depressant drugs, presence of fever or infection, or changing from parental to average oral equianalgesic dose of narcotic. When these factors were corrected, mental function improved and remained stable despite resumption of the previous narcotic dose. Delirium occurred more frequently in patients over 65, while oversedation without delirium was more frequent in the younger group. For some patients with advanced metastatic cancer, pain relief and intact mental status cannot coexist. For others, correction of factors other than narcotics which can impair function can often lead to improved mental status without decreasing narcotic dose or decreasing the degree of pain control.

Adult↗
PubMed1981

Interactions of glucose-6-phosphate dehydrogenase deficiency with drug acetylation and hydroxylation reactions.

We hypothesize that the bimodal distribution of hemolytic response by G6PG-deficient individuals to particular drugs such as sulfones may be due to the genetically determined acetylation rate of those drugs. Since metabolism, e.g., hydroxylation, may be required for these drugs to become hemolytic, genetically and environmentally determined variation in hydroxylation of a drug may also contribute to this variability in hemolytic response. To test the possibilities that acetylation and hydroxylation alter the hemolytic potential of these drugs, we incubated G6PG-deficient and normal red cells with mouse liver microsomes at two states of hydroxylase activity (uninduced and induced), an NADPH-generating system, and acetylated or unacetylated drug. We then measured GSH depletion in the cells as an indicator of prelytic cell damage. We found that in the presence of induced (high hydroxylase activity) microsomes, thiazolsulfone (Promizole) or DDS in unacetylated form caused the highest level of GSH depletion in G6PD-deficient red cells. Acetylation protected against GSH depletion. The specificity of the hydroxylation reaction in producing marked GSH depletion was shown by the protective effect of a specific hydroxylation inhibitor. Our results indicate that G6PD-deficient, genetically slow acetylators, having high microsomal activity, would be most susceptible to Promizole- or DDS-induced hemolysis, compared to other metabolic phenotypes. In addition, the bimodality in hemolytic response to Promizole probably corresponds to the bimodal distribution of acetylator phenotype in the population.

Acetylation↗
PubMed1981

Pharmacogenetic interactions in G6PD deficiency and development of an in vitro test to predict a drug's hemolytic potential.

To summarize our results and their implications, by adding induced mouse liver microsomes to an in vitro test for the hemolytic potential of a drug in G6PD deficiency, we found that: 1) Hydroxylation appears to play an important role in activating the hemolytic potential of many drugs. 2) Use of an in vitro test system combining drug, hydroxylation system and red cell, appears to be very reliable in ruling out hemolytic potential, when it is in fact absent, and about 80% effective in identifying hemolytic potential when it is present. 3) Acetylation seems to markedly reduce the hemolytic potential of two drugs studied: promizole and DDS. The genetic polymorphism in acetylation may explain the bimodal response to promizole. 4) These studies suggest that interaction among three pharmacogenetic systems produces a given hemolytic result. Variability of hydroxylation and acetylation rates can be expected to contribute to variability in individual responses to certain hemolytic drugs.

Animals↗