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PubMed2003

Risk factors of status epilepticus in children.

BACKGROUND: Although there is abundant literature about the morbidity and mortality rates of status epilepticus (SE), little is known about the risk factors of this medical emergency. The aim of the present study is to assess the risk factors of SE in children. METHODS: The authors reviewed the medical records of 83 patients admitted to the Pediatric Neurology Unit of Trakya University Hospital, Edirne, Turkey from January 1994 to December 2001 with the diagnosis of SE. Eighty-three patients were compared with 166 controls who were admitted to the same unit due to non-status epilepticus (non-SE) seizure. RESULTS: The univariate analysis demonstrated that SE episodes were significantly associated with a history of birth asphyxia, neonatal seizure, discontinuation of antiepileptic medication, epilepsy, partial seizure evolving to secondary generalized seizures, myoclonic seizure, generalized abnormalities in the neurological examination, neuromotor retardation, generalized background abnormalities on electroencephalogram (EEG), generalized abnormalities on neuroimaging and polypharmacy than non-SE episodes. Logistic regression was used to test the independence of these parameters as predictors of SE risk. Four parameters emerged as significant independent predictors of SE in children in multiple logistic regression: polypharmacy (Odds ratio (OR) 5.17, P = 0.0004), discontinuation of antiepileptic medication (OR 4.04, P = 0.0095), neuromotor retardation (OR 4.03, P = 0.0016) and generalized background abnormalities on EEG (OR 2.48, P = 0.0419). CONCLUSION: Polypharmacy, discontinuation of antiepileptic medication, neuromotor retardation and generalized background abnormalities on EEG are indicators in children of a higher risk of SE.

Adolescent↗

PubMed2004

Patterns of antipsychotic utilization in a tertiary care psychiatric institution.

OBJECTIVE: To perform a retrospective survey of discharge medications at a tertiary care psychiatric facility in an attempt to gain insight into, and perhaps an understanding of, the most recent pattern of antipsychotic utilization in patients with a diagnosis not restricted to schizophrenia. METHODS: This is a retrospective survey that used the Department of Pharmacy's computer database to obtain relevant discharge information on all non-geriatric patients discharged from Riverview Hospital between 1 January and 31 December 2000. The records of 372 patients met the inclusion criteria and formed the database for the survey. RESULTS: The results of this survey revealed a relatively high prevalence of antipsychotic polypharmacy (the use of two antipsychotics). Perhaps surprisingly, the highest rate of antipsychotic polypharmacy was found in individuals diagnosed with schizoaffective disorder (49.3%), followed by schizophrenia (44.7%), bipolar disorder (29.9%), and psychosis not otherwise specified (22.5%). CONCLUSION: Although antipsychotic polypharmacy is not a new phenomenon in schizophrenia, this study is the first to document its employment among other diagnoses.

Adult↗

PubMed2004

A systematic literature review of factors affecting outcome in older medical patients admitted to hospital.

INTRODUCTION: The ACMEplus project aims to devise a standardised system for measuring case-mix and outcome in older patients admitted to hospitals in different parts of Europe for primarily 'medical' (i.e. not surgical or psychiatric) reasons. As a first step in this project, a systematic review was carried out to identify factors which had a significant influence on outcome in such patients. METHODS: The systematic search used Medline 1966-2000, Cinahl 1982-2000, Web of Science 1981-2000, reference lists of relevant papers and a hand search of Age and Ageing 1974-2000. A six-category grading system was devised to classify the 313 identified papers with regard to their relevance to the ACMEplus project, study design and power. The analysis of the 14 'category 1' papers is presented. RESULTS: The main areas of assessment of case-mix were function, cognition, depression, illness severity, nutrition, social elements, aspects of diagnosis and demographic details. Statistically significant predictors, for the four outcome measures, listed below were: For length of stay: functional status score, illness severity, cognitive score, poor nutrition, comorbidity score, diagnosis or presenting illness, polypharmacy, age and gender. For mortality: functional status score, illness severity, cognitive score, comorbidity score, diagnosis or presenting illness, polypharmacy, age and gender. For discharge destination: functional status score, cognitive score, diagnosis or presenting illness and age. For readmission rate: functional status score, illness severity, co-morbidity, polypharmacy, diagnosis or presenting illness and age. CONCLUSIONS: Factors affecting outcome in older medical patients are complex. When looking at outcomes of hospital admission in older people it is important not just to look at routinely available statistics such as age, gender and diagnosis but also to take into account multifaceted aspects such as functional status and cognitive function.

Aged↗

PubMedDate not supplied

Teratogenicity of antiepileptic drugs: analysis of possible risk factors.

To determine the primary factors responsible for the increased incidence of malformation in the off-spring of antiepileptic drug (AED)-treated epileptic mothers, special attention was paid to drug combinations in a prospective study of 172 deliveries. Variables used for analysis were eight antiepileptic drugs (AEDs) and total daily dosages (drug score), and seven background factors consisting of maternal age at delivery, gravida, outcome of previous pregnancy, etiology and type of epilepsy, occurrence of seizures in the first trimester of pregnancy, and seizure frequency during pregnancy. The overall rate of malformation was 14.0%. Thirty-one patients were administered a single drug, and the rate of malformation was 6.5%. The remaining 141 patients were treated with multiple AEDs, and the rate of malformation was 15.6%. The drug score of the latter group was significantly higher than the former (p = 0.01). There was no definite dose-dependent increase in the incidence of malformations associated with any individual AEDs. There was no relationship between the type of defect and individual AEDs. Wilcoxon rank-sum test revealed significant association between the drug score, valproate (VPA), and congenital malformation. Carbamazepine (CBZ) also reached an almost significant level. Furthermore, VPA polypharmacy produced the highest incidence of malformation, higher than that produced by any other AED or drug combination. There was no significant association between the presence of malformations and the other putative risk factors. These results suggest that high dose of AEDs reflecting polypharmacy, VPA polypharmacy in particular, are primary factors responsible for the increased incidence of congenital malformation in the offspring of treated epileptic mothers.

Abnormalities, Drug-Induced↗

PubMed1996

Geriatric targeting criteria as predictors of survival and health care utilization.

OBJECTIVE: To assess the utility of geriatric targeting criteria in predicting survival and health care utilization in a cohort of hospitalized older veterans. DESIGN: A prospective cohort study assessing geriatric targeting criteria, e.g., polypharmacy, falls, or confusion, with respect to adverse outcomes at 12 months. SETTING: A Tertiary Care VA Medical Center. PATIENTS: 507 acutely hospitalized male veterans aged 65 years or more. MAIN OUTCOME MEASURES: Survival status, nursing home placement, and total hospital days during 12 months following hospital admission. RESULTS: Patients who had a higher number of targeting criteria at admission showed a significantly increasing trend toward death (P < or = .001), nursing home placement (P < or = .01), and longer hospital stays (P < or = .01) at 12 months. In univariate analyses, weight loss (relative hazard 3.8, 95% CI 2.4, 5.9), appetite loss (relative hazard 3.3, 95% CI 1.9, 5.8), depression (relative hazard 2.5, 95% CI 1.4, 4.5), falls (relative hazard 2.2, 95% CI 1.2, 4.1), confusion (relative hazard 2.2, 95% CI 1.2, 4.0), and socioeconomic problems (relative hazard 1.6, 95% CI 1.0, 2.5) predicted death. Polypharmacy (OR 3.4, 95% CI 1.3, 8.8), confusion (OR 4.4, 95% CI 1.5, 13.0), and prolonged bedrest (OR 7.6, 95% CI 1.5, 39.3) predicted nursing home placement. Confusion (Beta 12.0, 95% CI 2.9, 21.3), falls (Beta 14.2, 95% CI 4.2, 24.3), and prolonged bedrest (Beta 22.4, 95% CI 3.9, 41.0) predicted total hospital days. In multivariate analyses, weight loss, depression, and socioeconomic problems predicted death; confusion and polypharmacy predicted nursing home placements; and falls predicted total hospital days. CONCLUSION: This prospective cohort study of hospitalized older veterans demonstrated geriatric targeting criteria as predictors of adverse hospital outcomes. Our findings suggest screening acutely hospitalized patients using chart abstracted geriatric targeting criteria is useful in identifying patients at risk for adverse outcomes of hospitalization.

Activities of Daily Living↗

PubMed2006

The prescription of psychotropic drugs in psychiatric residential facilities: a national survey in Italy.

OBJECTIVE: This paper reports the prescriptions of psychotropic drugs made to 2962 patients living in 265 residential facilities (RFs) in Italy. METHOD: Structured interviews were administered to RF managers and staff to obtain data on patients' sociodemographic and clinical characteristics; information about current drug prescriptions were obtained from clinical records. RESULTS: Polypharmacy was common: on average, each treated patient was taking 2.7 drugs (+/-1.1). The association of one atypical antipsychotic with one benzodiazepine represented the most common prescription profile. The variable most consistently associated with a higher likelihood of receiving polypharmacy was a history of admission to an acute general hospital psychiatric ward in the previous 12 months. Many prescriptions were loosely related to specific diagnoses. CONCLUSION: Psychotropic drug prescription patterns for severe patients living in RFs are characterized by substantial rates of polypharmacy. Specific guidelines may be helpful for long-stay patients living in RFs, who exhibit complex care needs.

Adult↗

PubMed1999

A prospective survey on drug choice for prescriptions for admitted patients with schizophrenia.

A survey on psychotropic drugs prescribed for the treatment of schizophrenia was implemented in order to obtain basic data required for revision of the Japanese Psychopharmacology Algorithm (1998). The subjects comprised 94 inpatients with schizophrenia (ICD-10) in seven public hospitals. A questionnaire was conducted to record age, gender, age at start of treatment, treatment period, compliance, frequency of admission and diagnostic classification. A mean dose of chlorpromazine base at 420 mg/day was prescribed to the subjects (six men vs four women; mean age: 32.4 years). The average number of psychotropic drugs prescribed together is 4.0 (1.8 for neuroleptics). The mean treatment period is 5.9 weeks. Antiparkinson drugs, hypnotics, anxiolytics, antimanics/antidepressants and antiepileptics are concurrently used in 92, 85, 25, 6.8 and 2.1% of cases, respectively. Prescriptions are changed 1.8 times on the average. In 84% of the patients, good response to the overall treatment is observed. Polypharmacy is carried out in more than 90% of the patients, although clinical psychopharmacological evidence for the benefits or disadvantages of polypharmacy are insufficient. A large-scale survey is required to revise the algorithm for treatment-refractory schizophrenia, because treatment-refractory and long-term hospitalized patients are rarely included in this survey. False intractable cases due to inadequate treatment such as long-term polypharmacy at a high dose may be included when the scope of subjects is enlarged.

Adult↗

PubMed2002

Combination of drugs in the management of diabetes mellitus.

Combination of drugs or polypharmacy is a therapeutic procedure and this can be needed in diabetes also. To consider the basis of polypharmacy, certain knowledges regarding likely mechanism operating in diabetic patient are to be known. Drugs available in polypharmacy are well elaborated in this article. The drugs can be categorised in three headings: Obese type 2 diabetes mellitus, non-obese or standard weight diabetes and low body weight subjects. Severity of hyperglycaemia is another factor to be looked into while treating type 2 diabetic patients. Besides, certain other situations are narrated where the combination therapy can be helpful.

Body Weight↗

PubMed2003

[Clinically relevant drug interactions in the elderly].

About 15% of hospital admissions of elderly patients in the Netherlands are caused by adverse effects of drugs. With polypharmacy there is an increased chance of adverse effects occurring. It is not always possible to reduce polypharmacy in the elderly. Polypharmacy is often associated with drug interactions which result in an increased or decreased effect, or the occurrence of adverse effects. Due to changes in the pharmacokinetic and pharmacodynamic properties of drugs in the elderly, the effect of interactions is more clinically relevant. Pharmacokinetic interactions influence absorption, liver metabolism or excretion by the kidneys. In particular, interactions with drugs that have a narrow pharmacotherapeutic spectrum can result in serious adverse effects: anticonvulsives, anti-Parkinson drugs, antipsychotics, coumarin derivates, digitalis preparations, lithium salts, opiates, sulphonylurea derivates, tricyclic antidepressants and verapamil. The most important pharmacodynamic changes in the elderly concern an increased sensitivity of the target organ. This is particularly the case for substances which have an effect on the central nervous system, such as antidepressants and antipsychotics, but also applies to benzodiazepines, coumarin derivatives and digoxin. When an unexpected adverse effect occurs in a patient or a previously effective therapy suddenly fails, it is wise to consider drug interaction as a possible cause.

Aged↗

PubMed1992

The influence of other anticonvulsants on the plasma concentration of E-2-en-valproate.

E-2-en-valproate is a major metabolite present in the blood of humans treated with valproate. In animals it is a potent anticonvulsant. We have measured concentrations of valproate and E-2-en-valproate in 102 plasma samples obtained from 75 adult patients (20 taking valproate only; 55 taking valproate and other anticonvulsants) under steady-state conditions. The two groups' mean ages and weights were comparable. The average valproate daily dose was lower (p < 0.002) in the monotherapy group (1152 +/- S.D. 661 mg/d) than in the polypharmacy group (1902 +/- S.D. 874 mg/d). Despite this, the mean plasma levels of valproate and E-2-en-valproate were significantly higher (p < 0.05, p < 0.0001, respectively) in the monotherapy group (60.0 +/- S.D. 22.6 micrograms/ml; 3.00 +/- S.D. 1.40 micrograms/ml, respectively) than in the polypharmacy group (49.5 +/- S.D. 24.8 micrograms/ml; 1.73 +/- S.D. 0.95 microgram/ml). While the mean plasma valproate level was 17.5% lower in the polypharmacy group, the mean plasma E-2-en-valproate level was 42% lower. The co-administration of other anticonvulsants significantly reduced the concentration of valproate and, more so, of E-2-en-valproate in plasma.

Adult↗

PubMed1987

Epilepsy in a Doncaster practice: audit and change over eight years.

The results of active management and the findings of repeated audits of epilepsy care over the period 1978-86 in a general practice are described. It was found that about one-fifth of epileptic patients continued to have frequent seizures, usually complex partial, about half had few seizures, and many with mild epilepsy remitted early.By 1980 attempts to reduce polypharmacy, change treatment and achieve optimal use of anticonvulsant drugs in epileptic patients with frequent seizures or side effects had led to an overall improvement in seizure control in 27%, a reduction of polypharmacy in 24% and an improvement in well-being in many patients. Subsequently it proved possible to maintain this improvement, to achieve similar results in epileptic patients joining the practice and to avoid misdiagnosis and polypharmacy in newly diagnosed patients.General practitioners can make a considerable contribution to the care of patients with epilepsy but improved overall care requires better collaboration between neurologists and other clinicians. A district epilepsy service, based on a local clinic, which actively pursues a collaborative approach is suggested as the model for providing optimum care to epilepsy patients.

Anticonvulsants↗

PubMed2004

Life long changes in cognitive ability are associated with prescribed medications in old age.

OBJECTIVES: To determine the association between prescribed medication and life long changes in cognitive ability. DESIGN: Retrospective cohort study. SETTING: Community residents of a largely urban region of South East Scotland. PARTICIPANTS: Four hundred and seventy-eight survivors of the 1932 Scottish Mental Health Survey (n=87,498) without dementia. MEASUREMENTS: The Moray House Test (MHT) of intelligence administered at age 11 and age 80 years. Hospital Anxiety and Depression Scale (HADS) score, history of disease and current prescribed medications age 80 years. RESULTS: After adjusting for sex, neuroactive drugs had a detrimental effect on life long cognitive change age (F=12.2, p=0.001, partial eta-squared=0.026), statins a beneficial effect (F=5.78, p=0.017, partial eta-squared=0.013) and polypharmacy a detrimental effect (F=6.46, p=0.011, partial eta-squared=0.014). In the optimal model estimated marginal means revealed: a relative improvement for statin users, IQ age 11=93.2 (95% CI 87.9-98.4) and age 80=100.6 (95% CI 95.3-105.9); compared with non-users, IQ age 11=100.9 (95% CI 99.4-102.3) and age 80=100.0 (95% CI 98.6-101.5). CONCLUSIONS: Clinically, the degree to which drugs impair cognition in relatively fit, older people may not be apparent. However, in population terms, medication use, particularly polypharmacy, is important. Statins, used as currently indicated for cardiovascular disease, appear promising in ameliorating cognitive decline in older people. However, firm recommendation of their use should await the outcome of ongoing randomised clinical trials.

Aged↗

PubMed2005

Determinants of medicine use in a Swedish primary health care practice population.

BACKGROUND: Pharmaceuticals represent an increasing share of private and public health care expenditures. The aim of this study was to characterise users and to determine the pattern of uses of prescribed medicines and to identify determinants of medicine use in a multi-ethnic Swedish general practice population. METHODS: The study was performed in 1055 of 1442 consecutive adult patients visiting the Jordbro Health Centre (JHC) in Stockholm, Sweden. RESULTS: In a regression analysis adjusted for the influence of confounders, subjects reporting 10-30 complaint symptoms, subjects with chronic disease and subjects that had a cost limitation card all reported a higher number of used medicines than subjects with a few (0-10) symptoms and those without chronic disease and a cost limitation card. In a Poisson's regression analysis, high age, female gender, not working, more than 10 symptoms, chronic disease and having a cost limitation card were related to use of prescribed medicines. All included variables predicted 19% of the explanation. Marital status, multi-symptomatology, chronic disease and having a cost limitation card were related to polypharmacy in a logistic regression analysis. CONCLUSION: A high number of complaint symptoms, chronic disease and having a cost limitation card were all significantly and independently related to use of medicines and polypharmacy.

Adolescent↗

PubMed2003

A population-based study of drug use in the very old living in a rural district of Sweden, with focus on cardiovascular drug consumption: comparison with an urban cohort.

PURPOSE: To describe drug use among the elderly, with focus on cardiovascular drugs and regional differences. METHODS: Cross-sectional data from a Swedish population-based study on ageing and dementia were used. In rural Nordanstig, drug-use data for 918 participants, 75 years and older (N1), were collected during the period 1995-1998. The data for 335 participants, 84 years and older (N84+), were compared with 418 subjects of the same age group in urban Kungsholmen (K5), data collected 1997-1998. RESULTS: Over 90% of the participants were using drugs regularly or 'as needed'. The most common were cardiovascular drugs, nervous system drugs and drugs for the alimentary tract and metabolism. Polypharmacy (five drugs or more) was common, especially among the oldest, 46% (N84+) and 50% (K5). ACE-inhibitors were used by only 24% of the N1 participants with heart failure. Significantly fewer of cognitively impaired participants were treated with ACE-inhibitors (OR: 0.44) and beta-blockers (OR: 0.50). Significant regional differences among the oldest old were found, with more cardiovascular (OR: 2.72) and less antithrombotic drugs (OR: 0.43) in the rural 84+ group. CONCLUSIONS: The extensive drug consumption, high prevalence of polypharmacy and regional differences stress the need for rigorous monitoring of drug use in the elderly. The data also indicate undertreatment of some cardiovascular diseases in the elderly with cognitive impairment.

Aged↗

PubMed2006

Detection of potential drug interactions - a model for a national pharmacy register.

OBJECTIVE: The widespread use of pharmaceuticals prescribed by different physicians has caused the Swedish government to propose a new legislation with registration of all prescriptions dispensed at the Swedish pharmacies. In the present study, we wanted to examine the frequency, distribution and determinants of potential drug interactions. METHODS: The prescriptions from all individuals (n=8,214) with two or more prescriptions during October 2003 to December 2004 were collected from the ongoing Jämtland cohort study of a total of about 11,000 individuals. Potential drug-drug interactions were detected with a computerized interaction detection system and classified according to clinical relevance (types A-D). RESULTS: On average each individual filled 14.6 (men 14.3, women 14.8) prescriptions during the study period. 3.6% of the individuals used more than 15 different drugs. The number of detected potential drug interactions type A-D was 4,941 (men 1,949, women 2,992). The risk of receiving a potential interaction type A-D was estimated as the cumulative incidence 0.26 (2,116/8,214) overall, 0.22 (748/3,467) for men and 0.29 (1,368/4,747) for women during the 15-month study period. The age adjusted risk, RR(adj), for women was estimated as 1.30. Excluding sex hormones and modulators of the genital system, the RR(adj) was 0.96, with no elevated risk for women. For potential interactions type D, that might have serious clinical consequences, 167 (cumulative incidence 0.0203) individuals (72 men, cumulative incidence 0.0208, 95 women cumulative incidence 0.0200) were detected. The risk of receiving a combination of potentially interacting drugs was positively correlated to age and polypharmacy. The cumulative incidence for elderly was estimated as 0.36 (65-84 years) and 0.39 (85 years and above). The relative risk for individuals with 15 drugs or more was estimated as 3.67 (95% CI 3.46-3.90). CONCLUSION: In a general population there were relatively few severe potential drug interactions. The new Swedish national pharmacy register will provide health care professionals with a powerful tool to systematically review all prescriptions. An alert system should focus on the more potential drug interactions, type C-D, with close monitoring of elderly and patients with polypharmacy.

Adult↗

PubMed2004

Medication use in the elderly patient: focus on the perioperative/perianesthesia setting.

As the population ages, the use of multiple medications also increases. Polypharmacy (taking multiple drugs at a time) presents concerns to the perianesthesia nurse who is caring for the geriatric patient. The pharmacokinetics and pharmacodynamics of drugs are often altered in older adult patients. Adverse drug reactions and drug interactions occur more often in geriatric patients than in younger patients. For these reasons, the benefits and risks of multiple medications and the administration of certain types of drugs must be carefully considered in the elderly patient. The selection of any medication should be individually based on the benefits and risks. Adverse drug reactions play a significant role in hospitalization for the general population, and the elderly are more susceptible to these. These drug reactions often contribute to significant morbidity as well as mortality. Medications need to be considered carefully in the older adult patient, but perhaps more so in the perioperative/perianesthesia period. Drug interactions are diverse. The type of anesthesia may influence the patient's outcome, depending on the medications the patient is currently taking. The patient's response to the stress of surgery is also affected by individual medical conditions as well as medications the patient is currently receiving Polypharmacy, inappropriate medications, adverse drug reactions, drug-disease issues, and drug interactions in the geriatric population are concerns in the perioperative/perianesthesia setting.

Age Factors↗

PubMed2005

Social risk factors for hospital malnutrition.

OBJECTIVE: Disease severity is considered an important risk factor for malnutrition in hospitalized patients. We investigated the effect of social factors and disease parameters on the development of malnutrition. METHODS: Nutritional state was assessed by the Subjective Global Assessment in 794 consecutively admitted patients in two hospitals in Berlin (n = 493, university hospital; n = 301, district hospital). The influences of age, sex, social status, life habits, and disease parameters on nutritional state was analyzed with univariate and multivariate logistic regression methods. RESULTS: Malnutrition was diagnosed in 22% of patients. Its prevalence was significantly higher in patients with malignant than with benign diseases (odds ratio [OR] = 1.568, P < 0.05) and in patients with multiple prescriptions (OR = 1.154, P < 0.001), but no difference was found between medical or surgical patients. The strongest risk factors for malnutrition in univariate analysis were age older than 60 y (OR = 2.861, P < 0.001), living alone (OR = 1.769, P = 0.002), and achieving a lower level of education (OR = 1.589, P < 0.05). Therefore, multivariate analysis was performed after stratification for age. Demonstrated independent additional risk factors were polypharmacy (OR = 2.367, P < 0.001) and malignant disease (OR = 4.114, P < 0.001) in young patients and polypharmacy (OR = 1.109, P < 0.002) and living alone (OR = 1.830, P = 0.008) in patients 60 y and older. CONCLUSIONS: These data show that patients who are older, less educated, and live alone are at high risk of developing malnutrition. Thus special attention should be given to these risk groups when evaluating nutritional status and nutritional support.

Age Factors↗

PubMed2006

The aging lower urinary tract.

PURPOSE: Age related changes in continence and the GU system, and how they affect the management of LUT dysfunction are discussed. Guidelines are offered regarding the diagnosis and management of incontinence in the elderly population. MATERIALS AND METHODS: Published literature and current treatment practice specific to elderly patients with LUT dysfunction were reviewed. RESULTS: LUT symptoms in the elderly population are affected by the high prevalence of comorbidity and polypharmacy. In addition, the GU system undergoes age related changes that increase the risk of LUT dysfunction. CONCLUSIONS: Incontinence in older persons is almost always caused by multiple factors, of which not all are directly related to the GU system. Issues such as polypharmacy, comorbidity, and the increased risk of medication side effects must be considered in planning treatment. The primary care physician and urologist or gynecologist should establish a partnership to co-manage the broad spectrum of factors affecting continence in elderly patients.

Age Factors↗