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PubMed2006

Concomitant medications may not improve outcome of antipsychotic monotherapy for stabilized patients with nonacute schizophrenia.

BACKGROUND: There are virtually no controlled data suggesting that concomitant psychotropic medications (CPMs) improve outcome in schizophrenia after the acute phase. Despite that, polypharmacy (with all of its disadvantages) is far more common than monotherapy. To our knowledge, there have been no published reports of prospective systematic investigations of the efficacy of unrestricted CPM use in nonacute schizophrenia. METHOD: This was a naturalistic, systematic study using a sample of 53 stabilized patients with DSM-IV-TR schizophrenia from 1 clinical practice setting including both private patients and patients from controlled research studies of the effectiveness of antipsychotics. Since there are meager controlled or systematic data on the effectiveness of CPM use with antipsychotics in nonacute schizophrenia, we tested the clinical strategy of CPM use by gradually tapering all CPMs (except antianxiety agents). The aim was to determine if the CPM improved outcome, had no effect, or worsened outcome using the Clinical Global Impressions-Improvement scale before and after taper, over at least 3 months and in some cases up to 18 months after discontinuation. Data were gathered from July 2002 to June 2005. RESULTS: For 21 patients undergoing 22 antidepressant tapers, no change was noted in 18 of 22 tapers, while in 3 improvement was noted and in 1 worsening was noted. For the 12 patients on treatment with mood stabilizers, no change was noted in 10 of 13 discontinuations, while in 3 mild worsening was noted. One patient was on treatment with both modafinil and trazodone and reported no change after tapering each in separate discontinuation trials, while another 3 patients were taking sleeping medications and also noted no change after discontinuation. CONCLUSION: For most stabilized, chronic patients with schizophrenia, tapering adjunctive medications did not change outcome. This naturalistic study further defines the limits of efficacy of some concomitant classes of medications in patients with chronic schizophrenia who are already receiving adequate antipsychotic therapy.

Adolescent↗

PubMed2005

Drug utilization and potentially inappropriate drug use in elderly residents of a community in Istanbul, Turkey.

OBJECTIVE: This study investigates drug utilization and estimates the prevalence of potentially inappropriate drug use in a Turkish population aged 70 years or older. MATERIAL AND METHODS: A cross-sectional study was carried out on a total of 1019 participants who accepted face-to-face questionnaires in home interviews in Istanbul. All medications used in the three weeks prior to the study were recorded. Some major risk factors that might influence the use of inappropriate medication such as socio-demographic characteristics and concomitant disease such as depression and dementia were also questioned. Inappropriate drug use was assessed using the Beers criteria. RESULTS: Among the 1019 participants, 903 (88.6%) had been using at least one medication during the last three weeks. The average number of medications used was 2.9 +/- 2.0. The most frequently drugs used were cardiovascular drugs (39.9%), followed by analgesics/anti-inflammatory drugs (16.2%), vitamin/mineral preparations (10.6%) and central nervous system drugs (10.2%). Of the 1,019 participants, 9.8% were using one potentially inappropriate medication and one patient was using two inappropriate drugs. The most common of these drugs were reserpine (23.7%), dipyridamole (21.8%), antihistamines (14.8%), and benzodiazepines (10.9%). Only age and total number of medications were associated with potentially inappropriate drugs in the multivariate analysis. CONCLUSIONS: This study revealed that drug utilization and the prevalence of inappropriate medication use in the elderly were lower than in published reports from most developed countries. Furthermore, polypharmacy and higher age were the main risk factors for potentially inappropriate drug use in the elderly.

Age Factors↗

PubMed1999

Benzodiazepine use among the elderly in the community.

Benzodiazepines are the most commonly prescribed psychotropic drug in the elderly. Benzodiazepines with a long duration of action can produce marked sedation and psychomotor impairment in older people, and are associated with an increased risk of hip fracture and of motor vehicle crash. One thousand seven hundred and one individuals of 65 years and over, identified from General Practitioner lists, were interviewed using the Geriatric Mental State-AGECAT package and current psychotropic drug use was recorded. Benzodiazepines were classified as having a short or long elimination half-life. Two hundred and ninety-five (17.3%) individuals were taking a benzodiazepine, with use in females being twice that in males. Of the 295, 152 (51.5%) were taking a long acting benzodiazepine and the use of long acting anxiolytic type benzodiazepines was particularly common. Fifty-two (17.6%) benzodiazepine users were taking one or more other psychotropic drugs. A benzodiazepine was used by eight of 18 (44.4%) subjects with an anxiety disorder, 62 of 180 (34.4%) individuals with depression, and seven of 71 (9.9%) people with dementia. Four-fifths of older people on a psychotropic drug were taking a benzodiazepine, highlighting the importance of this class of drug in the elderly population. The choice of a benzodiazepine with a long duration of action, which have been shown to be associated with serious adverse events in the elderly in over one half of benzodiazepine users, is of concern. The potential for adverse effects was further accentuated by polypharmacy practices. The choice of benzodiazepine for an older person has important consequences and should be addressed in greater detail with primary care.

Aged↗

PubMed2000

[Psychiatric complications of pharmacotherapy--a review].

Various commonly used drugs with somatic indications may give rise to a host of partially serious psychiatric side-effects. This overview details important prescribed drugs of daily use and their psychiatric complications. The problems of elderly patients are particularly considered. Also, polypharmacy will be given special attention.

Age Factors↗

PubMed2001

[Increased consumption of drugs among the elderly results in greater risk of problems].

With aging comes an increasing prevalence of diseases and symptoms that frequently require pharmaceutical treatment. However, aging also brings about bodily changes that result in increased effects and prolonged action of many drugs. Multiple drug use--often termed polypharmacy--seen in many elderly individuals, is the most important risk factor for adverse drug reactions (ADR) and increases the risk of drug interactions and poor compliance. ADR's are responsible for about 10% of all hospital admissions of elderly patients. The drugs most commonly involved are cardiovascular, psychotropics and anti-inflammatory agents. Many of these ADR's are dose-dependent and preventable. Drug use has increased over the last few years, largely thanks to the availability of new and effective agents. This calls for increased vigilance and prudence in prescribing for the elderly.

Aged↗

PubMed2001

The reality of type 2 diabetes treatment today.

The 5-year targets set by the St Vincent Declaration for cardiovascular events and other diabetes outcomes have still not been met, despite concerted efforts to treat cardiovascular risk factors in this population. Since St. Vincent we have seen a new focus on the care of Type 2 diabetes towards multiple risk factor reduction, including blood pressure, lipids, smoking and glycaemic control. The other new concept is that insulin resistance is a key abnormality in the pathogenesis of Type 2 diabetes. The thiazolidinediones are a new class of drug that ameliorate insulin resistance, and we await to see if their use is associated with improved diabetes outcomes. The third key issue is that modern day diabetes care requires polypharmacy. However, adding several drugs to the list of medications taken by many patients with Type 2 diabetes may bring problems of compliance. A typical patient might be taking several tablets for diabetes, plus medications to address cardiovascular risk factors/disease and typical co-morbidities of an ageing population. There is evidence that adherence to therapy is a major issue in diabetes care. More research is needed to define ways of improving adherence [corrected].

Diabetes Mellitus, Type 2↗

PubMed2001

[Adverse effects of drugs in patients with heart disease lead to hospital care].

Polypharmacy in patients with cardiovascular disease leads to an increased risk of developing adverse effects. At the Department of Internal Medicine at Stockholm Söder Hospital we studied computerized records and discovered that 14% of those hospitalized patients who were on drug treatment for cardiovascular diseases were admitted due to problems or symptoms possibly caused by their drugs. Interactions were less common; the symptoms which warranted hospitalization were more often caused by additive pharmacological effects. Obviously, adverse effects of drugs decrease quality of life, cause unnecessary suffering and treatment, and are expensive for the health care system. Screening of computerized records helps us detect adverse effects, and facilitates prevention.

Adverse Drug Reaction Reporting Systems↗

PubMed2001

[Drug therapy in the old age. Drug effects in the elderly].

The frequency of multimorbidity in elderly patients may mislead the physician into practicing polypragmasy (polypharmacy), resulting in unpredictable drug interactions. Such interactions are a quite common cause of hospitalization in geriatric patients. Pharmacokinetics are often altered in the aged, and individualized medication should take into consideration not only the patient's age, liver and kidney function, but also the individual variability of hepatic metabolism and drug absorption from the gastrointestinal tract dictated by genetic polymorphism. Drug treatment in the elderly should always be carefully assessed as to its risks and benefits, and, where indicated, certain medications should be replaced by or omitted.

Age Factors↗

PubMed2002

Characteristics of centenarians admitted to a community teaching hospital.

BACKGROUND: The "oldest old" are the most rapidly growing segment of society, and clinicians will increasingly encounter this age group in this century. METHODS: To describe the characteristics of a special subgroup of the oldest old, the centenarians, we conducted a retrospective case series analysis of all patients 100 years of age and above admitted to a large community teaching hospital. RESULTS: Thirty-nine patients with a mean age of 101.3 years were admitted a total of 57 times during the 5-year study period. The main reasons for admission were hip fracture, stroke, and urinary tract infection. Patients admitted from nursing facilities were taking more medications than community dwelling patients, and patients who were confused on admission were more likely to be readmitted. Only 2 patients died. CONCLUSIONS: Polypharmacy is common in centenarians, especially in institutionalized patients, and confusion may be a useful predictor of subsequent readmission. In-hospital mortality, however, is low in this population.

Age Factors↗

PubMed2002

Using medications appropriately in older adults.

Older Americans comprise 13 percent of the population, but they consume an average of 30 percent of all prescription drugs. Every day, physicians are faced with issues surrounding appropriate prescribing to older patients. Polypharmacy, use of supplements, adherence issues, and the potential for adverse drug events all pose challenges to effective prescribing. Knowledge of the interplay between aging physiology, chronic diseases, and drugs will help the physician avoid potential adverse drug events as well as drug-drug and drug-disease interactions. Evidence is now available showing that older patients may be underprescribed useful drugs, including aspirin for secondary prevention in high-risk patients, beta blockers following myocardial infarction, and warfarin for nonvalvular atrial fibrillation. There is also evidence that many older adults receive medications that could potentially cause more harm than good. Finding the right balance between too few and too many drugs will help ensure increased longevity, improved overall health, and enhanced functioning and quality of life for the aging population.

Aged↗

PubMed2003

Conventional antipsychotic prescription in unipolar depression, II: withdrawing conventional antipsychotics in unipolar, nonpsychotic patients.

BACKGROUND: In a Hull and Holderness Community NHS Trust audit of prescribing in unipolar depression, 55 patients were identified as taking a redundant conventional antipsychotic with no apparent diagnostic indication. Concerns regarding these patients' polypharmacy, duration of treatment, and risk of long-term or undetected side effects led to their being contacted with a view to the discontinuation of conventional antipsychotic treatment. METHOD: All case notes were scrutinized to validate, as far as possible, the diagnosis of unipolar depression without psychotic features. Patients were invited for a review of their medication. Ratings of symptoms (Brief Psychiatric Rating Scale), depression (Hamilton Rating Scale for Depression), motor side effects (Abnormal Involuntary Movement Scale), and personal function (Independent Living Skills Survey) were made before and after conventional antipsychotic discontinuation. The study was conducted Autumn 1999-Spring 2000. RESULTS: None of the 55 patients were deemed to present comorbid depression secondary to any other diagnosis. One patient could not be contacted; 14 patients, who tended to be older, refused the review. Of the remaining 40 who were seen, 25 had already discontinued antipsychotic treatment; their chronicity of illness was half that of the 15 patients continuing antipsychotic treatment. However, only 11 of these 25 patients had their medications discontinued under consultant psychiatrist supervision following the audit; 14 patients had stopped medication of their own volition, or for unclear reasons. Of the remaining 15 patients, 13 had their conventional antipsychotic discontinued by us. There were clinically and statistically significant improvements in symptoms and side effects after antipsychotic treatment was discontinued, and a statistically significant improvement in personal health care function. CONCLUSION: In this small sample, discontinuation of nonindicated conventional antipsychotic treatment was associated with clear benefits. Conventional antipsychotics should be used with caution in nonpsychotic depressed patients, particularly in the long term. Reluctance to discontinue medication in more chronic patients may be misplaced.

Adult↗

PubMed2003

Sad but true: your father has dementia. An approach to announcing the diagnosis.

OBJECTIVE: To show that family physicians have an important role in caring for patients recently diagnosed with dementia. SOURCES OF INFORMATION: This article is based on the authors' clinical experience and on the recommendations of the Canadian Consensus Conference on Dementia. MAIN MESSAGE: The authors touch on themes often ignored in the literature, such as issues surrounding the first time patients and their families are confronted with a diagnosis of dementia. We show the advantages of informing patients of the diagnosis and refute arguments for keeping it a secret. We then describe aspects of anticipatory counseling, which should begin as soon as the diagnosis is made: natural evolution of the disease, risk factors, power of attorney, driving, medical follow up, risks of polypharmacy, resources for psychological support of caregivers, and orientation to community resources (for helping patients remain at home). CONCLUSION: Physicians must inform patients and their families of a diagnosis of dementia and provide anticipatory counseling so that families can prepare for the long-term responsibility of caring for someone with this disease.

Automobile Driving↗

PubMed2004

[Two out of three persons living in nursing homes for the elderly are treated with at least ten different drugs. A survey of drug prescriptions in the northeastern part of Skane].

Polypharmacy and high usage of psychotropic drugs have been seen in Swedish nursing homes for elderly. An increasing number of older people are prescribed inappropriate amounts, types and combinations of drugs. Adverse effects including sedation, confusion and increased risk of falls tend to occur in this population. In an analysis of the medication of 762 elderly persons living in community based nursing homes in the northeastern part of Skåne was found that two-thirds of the residents were prescribed ten or more drugs. One-third was prescribed on a regular basis three or more psychotropic drugs. Compared to recent Swedish studies it was found that lesser amounts of neuroleptics, anticholinergic drugs and long-acting bensodiazepines were used. The purpose of the study was to investigate the current situation concerning the quality and quantity of medication of elderly people in nursing homes in this part of Skåne. Thereafter draw plans for suitable actions to be taken to improve the use of drugs for the benefit of our older patients. It is important to instruct all personnel in the changes of pharmacokinetics and pharmacodynamics during the aging process. Further surveys of the medication in nursing homes are needed and should be held on a regular basis to increase the awareness of the physicians to the hazards of inappropriate drug use in an aging population.

Aged↗

PubMed2004

[Unit dose systems prepared for geriatric patients. I].

The project was carried out to facilitate and improve the quality of the use of drugs by geriatric patients aiming at the observation of the therapeutic regimen and the improvement of their compliance. The group under study comprised 15 clients living in a selected old people's home in the city of Brno, for whom the pharmacist prepared drugs into one-week blister dispensers on the basis of their health dossiers for a period of 6 months (February - July 2002). Polypharmacy occured in all patients included into a unit-dose preparation for drugs; they took on average 16 drugs in a week. The most frequently administered drugs belonged to the ATC groups of psycholeptics, anti-inflammatory and antirheumatic agents, peripheral vasodilators, antianaemic agents, cardiac therapy, diuretics, and vasoprotectives and venopharmaceuticals. The dimensions of the dispensers used and the size of individual blisters in them proved to be sufficient with an average number of 11 drugs dispensed weekly. The preparation of one-week drug dispensers was also evaluated from the standpoint of time consumption. The average time of preperation of dispensers by the pharmacist was 16 minutes 20 seconds. Time consumption was connected not only with the total number of drugs dispensed, but also with the frequency of drug dosing, splitting (halving, quartering) of drugs, and frequent changes in medication.

Aged↗

PubMedDate not supplied

[Polipharmacy in the antipsychotic prescribing in practices psychiatric out-patient clinic].

INTRODUCTION: Due to the lack of scientific studies in the psychopharmacological treatment of psychosis, the references advise against the use of antipsychotic polypharmacy (AP). This study investigates the situation of this matter and its relationship with the introduction of atypical antipsychotics (AA) in our daily out-patient practice. METHODS: The study group included 160 patients, with ICD-10 diagnosis of non-affective psychosis and illness evolution of at least two years, whose ages ranged from 18 to 65 years, without mental retardation, who came to the out patient clinic at least once during the first semester of 2002 and, in order to make a comparison, at least one other time 9 to 12 months before. The retrospective study was done using the clinical records. RESULTS: In both moments studied, more than 50 % of the patients (65 % and 63.4 % respectively) had AA as their only treatment. AP was 25.6 % and 26.9 % respectively, 19.4 % of all patients were always in AP. At the end of the study, patients on AP were being prescribed a higher dose of chlorpromazine equivalents per day (p < 0.001) and more anticholinergics (p < 0.001). CONCLUSIONS: Our results show that in out patient settings AA have been consolidated as the first treatment option and that AP is a very common and stable phenomenon.

Adolescent↗

PubMed2004

Prescribing in older people.

BACKGROUND: Prescribing medications to older people is difficult due to comorbidity, limited evidence for efficacy, increased risk of adverse drug reactions, polypharmacy, and altered pharmacokinetics. OBJECTIVE: This article describes the principles underlying clinical geriatric pharmacology including approaches to evaluating the evidence for risk and benefit, and adjusting dose for age related pharmacokinetic changes. DISCUSSION: The challenge for the general practitioner is to balance an incomplete evidence base for efficacy in frail, older people against the problems related to adverse drug reactions without denying older people potentially valuable pharmacotherapeutic interventions.

Aged↗

PubMed2004

[Heavy consumers of drugs--seen from the viewpoint of the community pharmacist].

BACKGROUND: Heavy users of medicines observed in the pharmacy give an indication of the extent of the phenomenon of polypharmacy, associated with health risks for the individual and a possible overuse of health-services resources. The objective of this study was to identify heavy users of medicines who may be exposed to drug interactions. MATERIAL AND METHODS: We checked prescriptions handed in to a community pharmacy over a period of one month in order to identify those patients who according to the computer system had bought ten or more different drug substances over the last four months. The drugs were checked against DRUID, a Norwegian drug interaction database. RESULTS AND INTERPRETATION: On the basis of a total of 9339 prescriptions, 216 users (2.3%) filled the inclusion criteria; 74% of them were women, 66% were aged 65 or above. A substantial number of potential interactions were detected; the most prevalent were associated with warfarin, NSAIDs and aspirin. Advising heavy users of medical drugs is a challenge for the community pharmacist. More information about this group is needed.

Aged↗

PubMed2005

[Effective treatment strategy in elderly breast cancer patients].

INTRODUCTION: High frequency of cancer in older people and the improvements in life expectancy do not allow older age to be a barrier to treatment. The age is one of the risk factors for breast cancer development, one third of all cases occur in women older than 70 years. AIM: To provide an overview of the available information on the main issues in the field of surgery, radiotherapy and medical approaches to the treatment of breast cancer in the elderly. METHOD: The author discusses the treatment of breast cancer in the elderly, based on the data of literature. RESULTS: The assessment of any patient is the first step in the treatment process, performance status is more important than age. In older women a correct evaluation includes not only the basic medical history and the cancer staging, but also a detailed assessment of health and environment that may interfere with the therapeutic approach of the patient. Age is not a limitation for surgery, without any comorbidity it is safe, and operative mortality is low. The body self-image is important for most old women, they also wish to keep their breasts, so a conservative surgery and adjuvant radiotherapy should be offered to all, as long as the stage permits it. The selection of patients who are candidates for axillary dissection is based on selective lymph sentinel node technique which provides an optimal nodal staging with a minimal morbidity. The results of radiotherapy are as good as in younger patients, elderly women tolerate radiotherapy well. The inability to travel to the radiation facility is often the reason for omitting the radiation treatment and to choose a modified mastectomy. A promising alternative to the standard radiation treatment is the concept of intraoperative radiotherapy. Breast cancer in the elderly women is more likely to be well differentiated tumour, containing oestrogen and progesterone receptors. Based on these favourable prognostic factors, endocrine therapy is the standard treatment in adjuvant and metastatic setting for older women. When all hormonal options have been exhausted, elderly women should be treated with chemotherapy. Older patients often use several drugs concomitantly, and this polypharmacy may lead to possible clinically significant changes in the cytotoxic agent pharmacology. Supportive care can improve compliance of patients to chemotherapy. The introduction of oral and weekly applied cytotoxic treatments will allow a broader spectrum of patients to benefit from chemotherapy, particularly those with a poorer performance status. CONCLUSIONS: The use of a multidimensional geriatric evaluation permits a better selection of the best and individualized therapeutic decision for each patient. The growing number of treatment options in the elderly breast cancer patients will lead to an increase in survival and contribute to an improvement in their quality of life.

Antineoplastic Agents, Hormonal↗