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At least 793 records · Page 44Linked to original sources

PubMed2002

Reduced mortality in treating acutely sick, frail older patients in a geriatric evaluation and management unit. A prospective randomized trial.

OBJECTIVES: Documentation of treatment effects in acutely sick frail older patients in geriatric evaluation and management units (GEMUs) is scarce. The present study evaluated whether treatment in a GEMU would reduce mortality as compared to traditional treatment delivered in the Department of Internal Medicine. DESIGN: Prospective randomized trial. SETTING: GEMU or general medical ward. PARTICIPANTS: Acutely sick frail patients aged 75 and older who had been admitted to the Department of Internal Medicine were randomly assigned to treatment in the GEMU (n = 127) or to the general medical wards (n = 127). The following inclusion criteria were used to target frail patients: chronic disability, acute impairment of single activity of daily living, mild/moderate dementia, confusion, depression, imbalance/dizziness, falls, impaired mobility, urinary incontinence, malnutrition, polypharmacy, vision or hearing impairment, social problems, or prolonged bedrest. INTERVENTION: In the GEMU, the treatment strategy emphasized interdisciplinary assessment of all relevant disorders, prevention of complications and iatrogenic conditions, early mobilization/rehabilitation, and comprehensive discharge planning. The control group received treatment as usual from the Department of Internal Medicine. After discharge neither group received specific follow-up. MEASUREMENTS: Mortality and causes of death. RESULTS: Mortality in the intervention and control groups, respectively, was 12% and 27% at 3 months (P =.004), 16% and 29% (P =.02) at 6 months, and 28% and 34% (P =.06) at 12 months. The hazard ratio was 0.39 (95% confidence interval = 0.21-0.72) at 3 months. The main cause of death was cardiovascular disease. CONCLUSION: Treatment of acutely sick, frail, older patients in a GEMU substantially reduced mortality.

Activities of Daily Living↗

PubMed2002

Obesity is associated with functional decline in community-dwelling rural older persons.

OBJECTIVES: This investigation sought to examine potential gender differences in the relationship between body mass index (BMI) and functional decline. DESIGN: Cohort study. SETTING: Rural Pennsylvania. PARTICIPANTS: Medicare managed-risk program participants (aged > or =65) in the Geisinger Health Plan. Mean age at study baseline was 71. Final analyzable sample was 2,634 participants. MEASUREMENTS: Self-reported weight, weight change, living and eating habits, alcohol and medication use, depression, dentition, and functional status were obtained upon enrollment and again between 3 and 4 years later. Measured height and weight were also recorded at enrollment. Functional decline was defined as any increase in reported limitations in activities of daily living or instrumental activities of daily living over the study period. Logistic regression was used to evaluate the relationship between BMI, as defined by current National Institutes of Health categories, and risk of functional decline while controlling for age, depression, and polypharmacy. The referent category was BMI 18.5 to 24.9. RESULTS: Women had a higher prevalence of reported functional decline than men at the upper range of BMI categories (31.4% vs 14.3% for BMI > or =40). Women (odds ratio (OR) = 2.61, 95% confidence interval (CI) = 1.39-4.95) and men (OR = 3.32, 95% CI = 1.29-8.46) exhibited increased risk for any functional decline at BMI of 35 or greater. Weight loss of 10 pounds and weight gain of 20 pounds were also risk factors for any functional decline. CONCLUSIONS: Obesity was a risk factor for functional decline in older persons of either gender. Change in body weight did not benefit function for many older persons.

Activities of Daily Living↗

PubMed2003

Syncope in the elderly: diagnosis, evaluation, and treatment.

Syncope is more common in older persons than in any other age group. Age-related physiologic impairments of heart rate, blood pressure, baroreflex sensitivity, and cerebral blood flow, in combination with a higher prevalence of comorbid disorders and concomitant medications, account for the increased susceptibility of older persons to syncope. A number of age-related factors confound the assessment of syncope in older persons. Examples include (1). more than one possible attributable diagnosis; (2). polypharmacy; (3). cardiovascular and cerebrovascular comorbidity; (4). amnesia for loss of consciousness; (5). lack of witness accounts; (6). syncopal events presenting as falls; and (7). coexistent cognitive impairment and dementia. Cardiovascular risk factors are increasingly recognized as key triggers for dementia, with enormous potential for early detection and intervention. One such possible risk factor is bradyarrhythmia. Successful interventions for cardiovascular disorders that cause syncope in the elderly have wider implications than control of syncopal events and include reductions in falls and possibly prevention or modification of cognitive impairment and dementia.

Accidental Falls↗

PubMed2001

Drug metabolism and drug interactions in the elderly.

In the elderly concomitant use of several drugs (polypharmacy) is very common. Thus, the risk for drug interactions might be increased in this population. Since most drugs are hepatically eliminated by various metabolic pathways, liver function has to be considered as an additional factor modifying drug response. This chapter focuses on the hepatic mechanisms of interactions, especially on various inhibitors and inducers of the most important cytochrome P450 isoenzymes involved in drug metabolism. In addition, age-dependent changes in liver function are addressed. Based on pharmacokinetic results with different probe drugs, some inconsistencies in this area are discussed. The most important metabolic drug-drug interactions are independent of the age of the patients. However, since elderly patients consume a greater proportional share of drugs, they represent a population at risk for interactions. Awareness of this clinical problem may help to diminish those risks.

Aged↗

PubMed2005

Symptom clusters in advanced illness.

OBJECTIVES: To review the four sets of symptom clusters commonly seen in patients with advanced illness, and their definitions, associated symptomatology, and management. DATA SOURCES: Research and review articles and textbooks. CONCLUSION: Symptoms of patients with advanced illness tend to occur not isolation, but in symptom clusters. The ability to cluster symptoms in both assessment and management reduces the use of polypharmacy, systemic toxicities, and improves the patient's quality of life. IMPLICATIONS FOR NURSING PRACTICE: It is important that the nurse providing symptom management for the oncology patient understand the importance of clustering certain symptoms together.

Anorexia↗

PubMed1999

Non-epileptic attack disorder (NEAD): a comprehensive review.

Non-epileptic attack disorder (NEAD) represents a well-recognized clinical problem with a reported incidence among individuals with a diagnosis of intractable epilepsy as high as 36%. A failure to identify this disorder may lead to certain risks for the patient including polypharmacy, anticonvulsant toxicity, hazardous intervention, social and economic demands and a lack of recognition or neglect of any underlying psychological distress. This review provides a description of NEAD in an historic and societal context and discusses the variety of terminology which has been applied to this psychophysiological phenomenon. Epidemiology and associated methodological limitations; and diagnostic and classification issues related to NEAD in comparison to epilepsy are considered. The problems of failure to recognize NEAD in comparison to epilepsy are considered. The problems of failure to recognize NEAD are outlined, and theoretical and empirical aetiological issues are discussed.

Culture↗

PubMed2001

Secondary insomnia: diagnostic challenges and intervention opportunities.

The assessment and treatment of secondary insomnia (SI), the most common form of insomnia, are often complicated. Establishing an accompanying disorder as causal rather than comorbid is the key to assessment, but can be difficult even for experienced clinicians. Treatment often focuses on the primary disorder. In many cases, however, there is reason to treat the insomnia directly (insomnia is partially independent, does not respond to treatment of the primary condition, or has been misdiagnosed as SI). Although hypnotic medications are frequently used, behavioral interventions may be the best treatment approach, providing better long-term management of symptoms. Older adults warrant special consideration as age-related illnesses, changes in drug absorption and metabolism, and polypharmacy make them especially susceptible to SI. Recent research suggests successful treatment of insomnia may also relieve the primary disorder and merits follow-up. Future research is also needed on the efficacy of psychological treatment for SI for specific disorders as well as for older adults.

Journal Article↗

PubMed2000

[Two out-of-the-ordinary (?) case reports an asthmatic disease].

This is a report on two cases of asthmatic disease presented to a general practitioner. After a prolonged course of many years during which the intensity of asthma varied, Ms K. suffered from constantly recurring exacerbations that required treatment with systemic corticosteroids. The reason was found to be an adrenocortical insufficiency suspected to be of iatrogenic origin. After various treatment attempts an optimal minimal therapy was found resulting in complete freedom from complaints, namely, a combination of fluticasone and 3 mg methylprednisolone. However, brief instruction and group training as well as freedom from complaints remained unsuccessful in keeping the patient compliant. Mr Pl had been suffering from allergic asthma since early childhood which escalated in 1982. Beclomethasone diproprionate (BDP) and Budesonid were not tolerated (hoarseness), so that polypharmacy became necessary. This could only be reduced after finding out that Flunisolid (Fls) was tolerated, so that stabilisation was achieved. Complaints were greatly reduced with sole inhalation of Fls and salbutamol. After having changed over to fluticasone it became possible to reduce salbutamol as stabilisation progressed, so that salbutamol was used only if required. Depending on the intensity of allergen exposure, complaints now occur in February/March only, requiring updating of the therapy in respect of dosage and number of drugs used. During the remaining part of the year a minimal therapy using one stroke of 250 micrograms fluticasone was found sufficient to ensure lasting freedom from complaints. Both patients reduced or terminated the treatment of their own accord despite freedom from complaints under minimal therapy and were reconverted to therapy compliance only after the peak flow values had dropped or the complaints had returned.

Albuterol↗

PubMed2001

Phenytoin-induced choreoathetosis in patients with severe myoclonic epilepsy in infancy.

We describe three patients with severe myoclonic epilepsy in infancy (SME) who suffer from choreoathetosis due to the adverse effect of phenytoin. Choreoathetosis appeared when these patients were 8, 19, and 21 years old, 2 days to 6 months after increasing the phenytoin dosage. Choreoathetosis disappeared when the phenytoin dosage was decreased. The two elder patients experienced episodic and rather paroxysmal onset of long-lasting choreoathetosis, requiring the differential diagnosis from degenerative disease. In one of the patients, an ictal SPECT revealed decreased perfusion in the basal ganglia contralateral to the unilateral choreoathetosis. Polypharmacy, including carbamazepine and zonisamide, may have facilitated the onset of choreoathetosis. Phenytoin-induced choreoathetosis in the patients with SME is an important differential diagnosis among degenerative disorders involving involuntary movements. The episodic and paroxysmal nature of this movement disorder can delay its diagnosis and effective treatment. Patients with SME appear to be particularly vulnerable to this side effect of phenytoin, indicating the possible involvement of basal ganglia in the pathophysiology of this type of epilepsy.

Adolescent↗

PubMed2003

Clinical characterisation of severe hypoglycaemia--a prospective population-based study.

AIM: To determine the clinical characteristics of severe hypoglycaemia (SH) in a nonselected German population. SH was defined as an event requiring intravenous glucose or glucagon injection. METHODS: The prospective population-based study screened sensitively for SH in a region with 200,000 inhabitants between 1997 and 2000. All 30,768 patients who presented to the regional central hospital emergency department, and 6,631 (85 %) of 7,804 patients attended by the emergency medical service in the region were given an initial blood glucose test to detect atypical hypoglycaemia. RESULTS: Altogether, 264 cases of SH were registered, which occurred either spontaneously (n = 14; 5 %), in subjects with type 1 (n = 92; 35 %) or type 2 diabetes (n = 148; 56 %), or in subjects with a non-classified form of diabetes (n = 10; 4 %). On the basis of the estimated local number of diabetic patients the annual rate of SH was 1.5 episodes per 100 patients in insulin-treated type 2 diabetics compared with a rate of 0.4 episodes per 100 patients for the overall group of type 2 diabetic patients. Nocturnal hypoglycaemia accounted for 44 % of episodes in patients with type 1 diabetes on intensified therapy but for only 25 % in patients with type 2 diabetes. 26 % of the hypoglycaemic individuals with type 1 diabetes had an impaired awareness of hypoglycaemia and thus recurrent hypoglycaemic episodes. Irrespective of the treatment, the most frequent contributing factors for SH in type 2 diabetic patients were advanced age (76 +/- 12 years), multimorbidity (3.6 +/- 2.6 concomitant diseases)--in particular renal impairment (54 % [80/148])--and polypharmacy (4 +/- 2.7 concomitant drugs). 34 % (50/148) of the subjects with type 2 diabetes lived in nursing homes or were cared for by a home nursing service. With standardised treatment zero mortality of SH in diabetic patients was achieved, only one non-diabetic died due to hepatic failure. CONCLUSION: In elderly, multimorbid patients approaching the insulin-deficient end of the spectrum of type 2 diabetes the risk of developing SH increases considerably, nearing that in patients with type 1 diabetes. In order to avoid SH in geriatric patients, the treatment targets should be defined critically, taking into account individual quality of life and life expectancy. Hypoglycaemia unawareness is a major risk factor for SH in type 1 diabetes.

Adolescent↗

PubMed2003

Risk of hypoglycaemia with oral antidiabetic agents in patients with Type 2 diabetes.

In patients with Type 2 diabetes, the appropriate intensity of glucose control is determined by age, life expectancy, and the presence of concomitant disease. Geriatric patients are especially susceptible to hypoglycaemia and therefore particular care should be taken in this group characterized by polypharmacy, renal or hepatic dysfunction, cardiovascular multimorbidity and malnutrition. As hypoglycaemia is a significant cause of morbidity and mortality, treatment regimens for diabetes should minimize the occurrence of hypoglycaemic episodes and be tailored to the patient's individual needs. The pharmacological options for treating Type 2 diabetes have increased considerably and the risk of hypoglycaemia of the currently available drugs varies considerably. Metformin, thiazolidinediones, and acarbose, oral antidiabetic drugs that decrease insulin resistance or postprandial glucose absorption, are associated with a low risk of hypoglycaemia. These drugs can also be used effectively in various combination regimens; however, by improving insulin sensitivity, combinations of metformin and thiolidinediones with sulphonylureas or meglitinides may considerably increase the risk of hypoglycaemia. On account of its complex pharmacoprofile glibenclamide is a problematic substance carrying a high risk of hypoglycaemia. There are limited preliminary data indicating that, under routine conditions, glimepiride may be associated with a lower risk of hypoglycaemia than glibenclamide and is no more likely to cause hypoglycaemia than other shorter-acting agents such as gliclazide and glipizide. Nateglinide and repaglinide as short-acting insulin secretagogues may be associated with a reduced risk of hypoglycaemia compared with glibenclamide, in particular when dosed flexibly. Repaglinide might be beneficial in individuals with renal impairment.

Clinical Trials as Topic↗

PubMed2004

Psychotropic drug use in psychiatric inpatients: recent trends and changes over time-data from the AMSP study.

A considerable number of new drugs were introduced over the last few years. In this report we analyze to what extent they have come to be used in clinical practice and what changes in drug use have resulted from the availability of the new compounds. For this purpose, data on drug use in 1995 and 2001 assessed at two reference days per year and per hospital within the drug safety program AMSP were compared for 10 hospitals that had been participating in both years. Atypical neuroleptics (NL) were used in 59.9 % of patients on NLs in 2001 (16.7 % in 1995), most frequently olanzapine, risperidone, clozapine, and quetiapine, in this order. Thirty-nine percent of patients still received typical NLs in antipsychotic indication (77.1 % in 1995), and 30.8 % received typical hypnosedative NLs (38.1 % in 1995). SSRIs, other new ADs, and TCAs were used in similar rates in 2001, i. e., in 40.5 %, 37.9 %, and 34.8 % of AD patients, respectively (1995 : 24.2 %, 6.2 %, and 72.3 %, respectively). Mirtazapine was the most common AD in 2001, followed by citalopram, sertraline, and doxepin. Hypnotics were prescribed more frequently in 2001 (17.6 % vs. 11.7 %), mostly BZD agonists at that time, whereas overall anxiolytic use (in approximately 30 %) hardly changed over time. Mood stabilizers and anti-dementia drugs were given comparatively rarely, even in pertinent diagnoses. Polypharmacy was observed in about three-quarters of patients on psychotropic drugs, with a trend towards increasing use over time. Combinations of two NLs, of NL + AD, and of NLs + anxiolytic were most common in both years. Twenty percent of patients on atypical NLs received typical antipsychotic NLs additionally; typical hypnosedative NLs were used along with typical antipsychotics and atypical NLs in 20 % and 22 % of patients, respectively. TCAs and either SSRIs or other new ADs were still the most common AD combinations in 2001. Data were also analyzed according to the main diagnostic categories.

Adolescent↗

PubMed2004

High dose antipsychotic use in schizophrenia: findings of the REAP (research on east Asia psychotropic prescriptions) study.

BACKGROUND: High-dose antipsychotic regimes (defined as the prescription of more than 1000 chlorpromazine-equivalents milligrams of antipsychotic per day) in the management of patients with schizophrenia are not uncommon, but most reports are from western countries. Recent functional neuroimaging studies have found that the previous notion concerning the use of antipsychotic medication, especially in high doses, was unsupported and untenable. METHODS: This international study examined the use of high dose antipsychotic medication and its clinical correlates in schizophrenia patients within six East Asian countries/territories. RESULTS: Within the study group (n = 2399), 430 patients (17.9%) were prescribed high dose antipsychotics. Antipsychotic use varied significantly between countries, with Japan, Korea, and Singapore using higher doses than the other countries. High dose antipsychotic use was associated with younger age in Japan (p < 0.001), longer duration of admission (p < 0.001), duration of illness (p < 0.001, particularly in Korea and Taiwan), positive psychotic symptoms (p < 0.001, particularly in Japan and Korea), and aggression (p < 0.05, particularly in Japan), and also with a higher likelihood of extrapyramidal and autonomic adverse effects (p < 0.05, particularly in China). Country, younger age, the presence of delusions and disorganized speech, polypharmacy, and receiving depot medication but not atypical antipsychotic drugs were important predictors of high antipsychotic use. CONCLUSIONS: This survey revealed that high antipsychotic dosing is not an uncommon practice in East Asia. It behooves the prescribing clinicians to constantly reevaluate the rationale for such a practice.

Adult↗

PubMed2005

Multi-targeted and aggressive treatment of patients with type 2 diabetes at high risk: what are we waiting for?

Results from many single risk factor intervention trials and the multi-targeted Steno-2 trial in the last few years have provided a strong case that management of type 2 diabetes in all age groups requires a structured and intensified approach that is far more than just glucocentric, an approach addressing additional cardiovascular risk factors including hypertension, dyslipidaemia, sedentary behaviour, smoking and dietary habits causing insulin resistance and pro-inflammation. This type of integrated therapy applied for almost 8 years to high-risk type 2 diabetic patients has cut the relative risk of macro-and microangiopathy by half. The treatment algorithms for multifactorial therapeutic packages do not harbour any revolutionizing novel drugs or previously untested behaviour modelling, but the success criteria seem to include an individualized and stepwise introduction of target-driven polypharmacy and simple but focused behaviour modelling with continuous education, motivation and trouble-shooting for treatment barriers identified for the patient and the care giver. It is high time we transfer these experiences and major health benefits gained in the 'green house' of controlled clinical trials to the community level. To facilitate this process it is of crucial importance to offer not only postgraduate training of diabetes care providers but also to identify and eliminate treatment barriers.

Clinical Trials as Topic↗

PubMed2005

Sleep in the geriatric patient population.

Older patients often suffer from sleep disturbances caused by age-related physiological changes, polypharmacy, changes in circadian rhythm, retirement, and loss of spouse. Many seniors have readily diagnosed sleep disorders that can be treated to achieve improvement in daytime somnolence or cognitive impairments. After a discussion of normal age-related changes in sleep, specific sleep pathologies common in the elderly will be reviewed, including sleep apnea, restless legs syndrome, advanced sleep phase syndrome, and rapid eye movement sleep behavior disorder.

Aging↗

PubMed2000

[Clinical presentation and therapy of Mycobacterium marinum infection as seen in 12 cases].

BACKGROUND AND OBJECTIVE: Mycobacterium marinum (M.m.) is the causative pathogen of skin infections that have been called "swimming pool granulomas". An increasing number of reports that deep structures are involved in these infections was the reason for studying the clinical presentation and response of the infection to different therapeutic regimens. PATIENTS AND METHODS: All patients (eight men, four women, age range 18-73 years) were included in whom, between january 1991 and February 1995, M.m. infection had been proven by culture. The clinical data of these patients were retrospectively obtained by standardized questionnaire. RESULTS: The infection was limited to the skin in four of the twelve patients, deep structures only were involved in three, and five had both. Infections limited to the skin were successfully treated with sulphamethoxazole and trimethoprim or with tetracyclines, while rifampicin, alone or in combination with ethambutol, was efficacious when deep structures were involved. No surgical intervention was--or should be--performed. CONCLUSIONS: Infections with M.m. often involve deep structures, even in the absence of the skin being involved. The term "swimming pool granuloma" is, therefore, misleading when the infection is limited to he skin. A history of a chronic and indolent course, frequent changes of doctor and striking polypharmacy in its treatment are pointers to this infection.

Adolescent↗

PubMed1998

[Anticonvulsant combination therapy: rational concepts versus real effectiveness].

Primary drug treatment of epilepsies is usually a monotherapy with an antiepileptic drug. This procedure causes less side effects as polytherapy and probably shows the same efficacy. Two third of patients with focal epilepsies are sufficiently treated with a single antiepileptic drug: 60% of patients with Grand mal and 22-30% of patients with complex focal seizures remain seizures free. An alternative monotherapy will suppress seizures in another 30% of patients. With polytherapy this is achieved in only 12% of the remaining patients, furthermore, side effects increase in polytherapy. Generalized epilepsies are usually treated with valproate monotherapy. Patients remain seizure free from absence in 60-90%, from myoclonic-impulsive seizures in 75-97% and from Grand mal in about 85%. Alternative monotherapy is less common because of the limited efficacy and possible side effects of drugs: ethosuximide does not control Grand mal and phenobarbitone may cause sedation. Thus, polytherapy is commonly initiated when monotherapy fails to control seizures (lamotrigine is often chosen as comedication). Rational polypharmacy is a term suggesting rational concepts in planning antiepileptic polytherapy leading to a superior anticonvulsant effect. However, this consideration is not based on or supported by clinical data. Yet, a combination of drugs which have no or little pharmacokinetic interactions seems to be a clinically relevant recommendation. Thus, newly developed drugs such as vigabatrin, lamotrigine or gabapentin are more frequently used as comedication with standard antiepileptic drugs.

Anticonvulsants↗

PubMed2001

Preventing drug interactions by online prescription screening in community pharmacies and medical practices.

BACKGROUND: Drug interactions have been shown to be preventable by computerized prescription entry and screening only in hospitals and not in community-based practice. METHODS: We retrospectively evaluated the effect of online prescription screening in community pharmacies and physician offices of one health maintenance organization, phased in during 3 consecutive 6-month periods in 1998 to 1999 (period I, system active only in 40% of pharmacies; period II, system active in 90% of pharmacies and 50% of physician offices; period III, system active in 95% of pharmacies and 90% of physician practices), on rates of prescriptions with-, patient exposure to-, and physician prescribing of-potential drug interactions. FINDINGS: Cumulative data included 775,186 patients given at least one prescription, by one or more of 5504 physicians, whose prescriptions were dispensed at 572 pharmacies. Dispensing of drug interaction prescriptions was reduced by 21.1% and by 67.5% in periods II and III compared with period I (odds ratio, 0.79; 95% confidence limit, 0.75-0.83 and odds ratio, 0.28; 95% confidence limit, 0.26-0.30, respectively). Patient exposure decreased only in those receiving 3 to 7 concurrent drugs (odds ratio, 0.80; 95% confidence limit, 0.71-0.90) with no reductions for patients who were given 2 drugs or 8 or more drugs. Only 19% to 25% of physicians wrote prescriptions for drugs that interact, but 85% of these repeated this pattern after being alerted. The proportion of prescriptions of drugs that interact that originated with a single prescriber, as opposed to 2 prescribers, decreased during the 3 periods from 0.81 to 0.74 and 0.69 (P <.001). INTERPRETATION: Computerized prescription entry and drug interaction screening in the community caused a 62.8% reduction in pharmacy-dispensed prescriptions with severe drug interactions and a 20% reduction in patient exposure to prescriptions with severe drug interactions; this reduction was negated by polypharmacy of 8 or more drugs. The effect of interaction alerts on physician prescribing patterns was limited.

Adult↗