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PubMed2005

Early evaluation of the risk of functional decline following hospitalization of older patients: development of a predictive tool.

OBJECTIVE: To develop a predictive tool that could be used on admission to identify older hospitalized people at risk of functional decline 3 months after discharge. METHODS: This was a prospective cohort study that included 625 patients aged 70 years and older (mean age 80.0 +/- 5.6 years) hospitalized by the way of the emergency room, for at least 48 h, in two academic hospitals. Three months after discharge, 550 patients remained for analysis. On admission, people were assessed for premorbid functional status with the activities of daily living (ADL) scale and instrumental ADL scale. Demographic and medical data, including cognitive function, falls, polypharmacy, comorbidity, continence, mobility and self-rated health, were collected. ADL functioning was re-assessed at discharge and 1 and 3 months later. Functional decline was defined as the loss of at least one point on the ADL scale between the premorbid and 3-month evaluation. Univariate analyses were used to select variables associated with functional decline. A logistic regression model was then constructed to predict functional status 3 months after discharge. RESULTS: Three months after discharge, 165 (31.5%) patients had declined. The predictive tool SHERPA includes five factors: age, impairment in premorbid instrumental ADLs, falls in the year before hospitalization, cognitive impairment (Abbreviated Mini Mental State below 15/21) and poor self-rated health. Sensitivity and specificity were 67.9% and 70.8%, respectively. CONCLUSIONS: Older people are at high risk of functional decline following hospitalization. On admission, a simple instrument can easily identify these patients, even though the performance of this instrument is moderate.

Activities of Daily Living↗

PubMed1996

Regulatory environment and psychotropic use in board-and-care facilities: results of a 10-state study.

BACKGROUND: Largely unsupervised administration of drugs and the potential for overuse of psychotropic agents in residential care facilities have emerged as major public policy concerns. In a large multistate study, we examined patterns of psychotropic prescription and use by facility licensure status and the extensiveness of state regulations. METHODS: Descriptive analyses were based on a sample of 2,949 residents from 493 board-and-care facilities in 10 states, drawn via a complex, multistage sampling design. States were purposively selected based on the stringency of their board-and-care regulatory system, and samples of facilities were drawn, stratified by licensure status and home size. Residents were randomly selected within the sampled facilities. Weighted analyses were performed with Software for Survey Data Analysis (SUDAAN), accounting for the complex sampling design. RESULTS: Approximately 43% of the residents were prescribed and 41% used at least one psychotropic agent, primarily on a routinely scheduled basis. Antipsychotics were prescribed to 22% and used by 21%; antidepressants were prescribed to 17% and taken by 16%; antimanic agents were prescribed to and used by 4%; and anxiolytics, sedatives, or hypnotics were prescribed to 17% and used by 14%. Among psychotropic users, over 50% had not had mental health services in the prior year; 25% had no psychiatric history. Among licensed facilities, prescription and use of psychotropics, particularly antipsychotics, was significantly higher among residents of homes located in states with limited regulatory systems. CONCLUSIONS: Results revealed high rates of psychotropic prescription and use, and not inconsequential levels of polypharmacy - within and across therapeutic classes - among board-and-care facility residents. Frequently, psychotropics were not used as an adjunct to alternative treatments, and were not associated with a psychiatric history. Extent of psychotropic use was related to the regulatory environment, suggesting that more extensive regulations and monitoring may reduce psychoactive drug use in board-and-care facilities, and more adequately ensure the appropriateness of such treatment.

Adolescent↗

PubMed1998

Aging and the liver: an update.

The issue of whether or not liver function is compromised in the elderly population remains unresolved. Numerous age-related changes in hepatic structure and function have been described, but many of these observations are qualitative, were made under suboptimal experimental conditions, or are simply contradictory. Changes in hepato-cellular structural parameters, e.g., increased hepatocyte size, increase in the number of binucleated cells, altered mitochondria, and endoplasmic reticulum, have been reported. However, quantitative morphological analyses have refuted many of these observations. There are few functional data that correlate with structural changes. Serum and biliary cholesterol appear to rise, predisposing elderly people to increased incidences of coronary disease and gallstones, respectively. The rate of liver regeneration declines in old animals, but the regenerative capacity remains unchanged, perhaps reflecting an age-associated reduction in the response to hepatotrophic factors. This senescent change has important clinical implications with regard to surgical intervention for liver disease, e.g., resection or transplantation. Nevertheless, most outcomes studies suggest that age alone should not be a determining factor in such clinical decisions. Geriatric patients exhibit a decline in the hepatic clearance of certain drugs and a marked increase in the frequency of adverse drug reactions, reflecting an increase in polypharmacy regimens and declines in liver volume and blood flow rather than reduced Phase I metabolism. Although the livers of elderly subjects are characterized by a decline in adaptive responsiveness and reduced reserve capacity, clinical tests suggest that liver function is well-maintained in this age group.

Aging↗

PubMed2005

Elderly patients with cognitive impairment have a high risk for functional decline during hospitalization: The GIFA Study.

BACKGROUND: We tested the hypothesis that cognitive impairment upon admission (CIA) and cognitive decline (CD) during hospitalization are associated with an increased risk for functional decline (FD) in older inpatients. METHODS: The Italian Group of Pharmacoepidemiology in the Elderly (Gruppo Italiano di Farmacoepidemiologia nell'Anziano, GIFA) project was a multicenter survey of 9061 older patients admitted to Italian hospitals between 1991 and 1997. CIA was defined as a Hodkinson Abbreviated Mental Test score <7 on admission. The percentage of participants who developed FD, defined as loss of the ability to perform without help one or more activities of daily living between admission and discharge, was compared in patients who did and did not have CIA, and between those who lost at least one point in Hodkinson Abbreviated Mental Test score (CD) and those who did not. RESULTS: Mean age was 77.4 years, and women represented 52.3% of the sample. CIA was present in 21.0% of the patients. During hospitalization, 176 patients (1.9%) experienced FD (4% of those with CIA vs 1.3% of those without CIA). In multivariate analysis, CIA was an important risk factor for FD (odds ratio 2.4; 95% confidence interval, 1.7-3.5; p <.001), independent of age, gender, comorbidity, polypharmacy, and disability on admission. CD occurred in 3.7% of the sample and was strongly associated with an increased risk for FD (odds ratio 16.0; 95% confidence interval, 10.8-23.6; p <.001). CONCLUSIONS: Elderly patients with CIA have a higher risk for FD. New strategies should be implemented to prevent FD in patients with cognitive impairment, who account for a high percentage of older persons who are admitted to hospitals.

Activities of Daily Living↗

PubMed2005

Concealed renal failure and adverse drug reactions in older patients with type 2 diabetes mellitus.

BACKGROUND: In elderly patients serum creatinine may be normal despite decreased glomerular filtration rate (GFR). The aim of this study was to evaluate the prevalence of this "concealed" renal failure, i.e., renal failure with normal serum creatinine levels, in elderly diabetic patients, and to verify whether it is a risk factor for adverse drug reactions (ADR) to hydrosoluble drugs. METHODS: We used data on 2257 hospitalized patients with type 2 diabetes mellitus enrolled in the Gruppo Italiano di Farmacovigilanza nell'Anziano study. On the basis of serum creatinine and calculated GFR, patients were grouped as follows: normal renal function (normal serum creatinine levels and normal GFR), concealed (normal serum creatinine levels and reduced GFR), or overt (increased creatinine levels and reduced GFR) renal failure. GFR was calculated using the Modification of Diet in Renal Disease (MDRD) equation. The outcome of the study was the incidence of ADR to hydrosoluble drugs during the hospital stay. The relationship between renal function and ADR was evaluated using Cox regression analysis including potential confounders. RESULTS: Concealed renal failure was observed in 363 (16.1%) of patients studied. Patients with concealed or overt renal failure were older, had more frequently cognitive impairment and polypharmacy, and had lower serum albumin levels than did those with normal renal function. Both concealed (hazard ratio = 1.90; 95% confidence interval, 1.04-3.48; p =.036) and overt (hazard ratio = 2.23; 95% confidence interval, 1.40-3.55; p =.001) renal failure were significantly associated with ADR to hydrosoluble drugs. The use of more than four drugs also qualified as an independent risk factor for ADRs to hydrosoluble drugs during hospital stay. CONCLUSIONS: Older diabetic patients should be systematically screened to ascertain the presence of concealed renal failure in an attempt to optimize the pharmacological treatment and reduce the risk of ADRs.

Aged↗

PubMed2006

Falls risk and functional decline in older fallers discharged directly from emergency departments.

BACKGROUND: There is currently no standard approach to falls risk assessment and management for older fallers presenting to the emergency department (ED) who are discharged directly home. Hence, this study was conducted to describe the prevalence of falls risk factors associated with older fallers presenting to the ED and to identify the factors associated with postdischarge decline in function in this group. METHODS: This cross-sectional study was performed with 300 community-dwelling individuals, aged 60 years or older, admitted to the ED following a fall, and discharged directly home. A home-based assessment after ED discharge was performed, which included the prevalence of falls risk factors, identification of functional decline, and objective measurements of balance, gait, depression, and falls efficacy. RESULTS: Fall-related injuries were sustained by 91% (95% confidence interval [CI], 87.2%-94.0%) of participants presenting to the ED. The most common falls risk factors identified in the home assessment were polypharmacy (79.0%, 95% CI, 73.9%-83.5%), home hazards (76.0%, 95% CI, 70.8%-80.7%), decreased balance (61.3%, 95% CI, 55.6%-66.9%), and arthritis (61.3%, 95% CI, 55.6%-66.9%). A decline in function was reported by 35% of participants (95% CI, 29.6%-40.7%). Sustaining a fracture, functional independence before the fall, being female, depression, and slower Timed Up and Go (TUG) scores were associated with a decline in function (p <.05). CONCLUSION: Older fallers discharged directly from the ED have a high prevalence of falls risk factors and are at risk of functional decline.

Accidental Falls↗

PubMed2006

Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after hospital stay.

BACKGROUND: Adverse drug reactions (ADR) negatively impact life quality and are sometimes fatal. This study examines the incidence and predictors of all and preventable ADRs in frail elderly persons after hospital discharge, a highly vulnerable but rarely studied population. METHODS: The design was a prospective cohort study involving 808 frail elderly persons who were discharged from 11 Veteran Affairs hospitals to outpatient care. The main outcome measure was number of ADRs per patient as determined by blinded geriatrician and geropharmacist pairs using Naranjo's ADR algorithm. For all ADRs (possible, probable, or definite), preventability was assessed. Discordances were resolved by consensus conferences. RESULTS: Overall, 33% of patients had one or more ADRs for a rate of 1.92 per 1000 person-days of follow-up. The rate for preventable ADRs was 0.71 per 1000 person-days of follow-up. Independent risk factors for all ADRs were number of medications (adjusted [Adj.] hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.05-1.10 per medication), use of warfarin (Adj. HR, 1.51; 95% CI, 1.22-1.87), and (marginally) the use of benzodiazepines (Adj. HR, 1.23; 95% CI, 0.95-1.58). Counterintuitively, use of sedatives and/or hypnotics was inversely related to ADR risk (Adj. HR, 0.14; 95% CI, 0.04-0.57). Similar trends were seen for number of medications and warfarin use as predictors of preventable ADRs. CONCLUSIONS: ADRs are very common in frail elderly persons after hospital stay, and polypharmacy and warfarin use consistently increase the risk of ADRs.

Adverse Drug Reaction Reporting Systems↗

PubMed1992

Generation: a corporate-sponsored retiree health care program.

Generation is a geriatric clinic program sponsored by Southern California Edison Company for the company's retirees and their dependents. This innovative program uses a multidisciplinary team approach, including a comprehensive health and psychosocial assessment, complete medication review, retiree advisors, health promotion programs, and case management services. In its pilot phase, Generation has served more than 175 Edison retirees and dependents aged 53-96. In addition to traditional medical care, participants receive aggressive intervention regarding polypharmacy problems, health education workshops, individual and group counseling, and access to community resources. Ongoing research seeks to evaluate the program's effectiveness in providing high-quality health care services while containing costs.

Aged↗

PubMed2003

Development of the family caregiver medication administration hassles scale.

PURPOSE: "Medication administration hassles" are the minor daily irritants that family caregivers experience when they assist a dependent family member with medication regimens. This study was designed to develop and test a multidimensional measure of the hassles in family caregiver medication administration. DESIGN AND METHOD: The authors employed a multiphase process (caregiver focus groups, instrument development, pilot testing, and field testing). Approximately 180 family caregivers representing diverse socioeconomic circumstances and racial or ethnic backgrounds participated in the study. The final version of the instrument consists of 24 items and four subscales: Information Seeking/Information Sharing (9 items, alpha =.92), Safety Issues (5 items, alpha =.83), Scheduling Logistics (7 items, alpha =.90), and Polypharmacy (3 items, alpha =.80). Overall scale reliability is.95, and test-retest reliability at 2 weeks is.84. IMPLICATIONS: Caregiver medication administration hassles represent a complex, multidimensional construct that warrants consideration in studies of contemporary family caregiver stress, strain, and burden.

Aged↗

PubMed1994

Antibiotics at the extremes of age: choices and constraints.

Infection is a frequent cause of morbidity and mortality at the extremes of life. Its treatment is complicated by a lack of specificity in the clinical findings and wider range of pathogens than in other patients. For these reasons empirical therapy must cover a wide range of pathogens and yet, because the clinical findings may not even be due to infection, it should be as non-toxic as possible. It is also essential to investigate intensely before therapy so as to stand the best chance of making an aetiological diagnosis and possibly allowing a change to more directed therapy. Neonates in particular, but also the elderly, are susceptible to age-associated antibiotic toxicities, such as those from tetracyclines and chloramphenicol. Polypharmacy in the elderly renders them particularly liable to drug interactions. Both age groups have altered pharmacokinetics of antibiotics, including differences in absorption, distribution and elimination compared with healthy adults, and therapeutic drug monitoring may be needed more frequently as a result.

Aged↗

PubMedDate not supplied

Postmortem tissue methamphetamine concentrations following selegiline administration.

Selegiline is a relatively new antiparkinson's drug whose metabolites include methamphetamine and amphetamine. A 72-year-old female with apparently suicidal intentions was found dead at her residence. The cause of death was listed as coronary heart disease with a history of polypharmacy. The tissue methamphetamine and amphetamine concentrations resulting from selegiline administration are presented in this report.

Aged↗

PubMed2003

Oxycodone involvement in drug abuse deaths: a DAWN-based classification scheme applied to an oxycodone postmortem database containing over 1000 cases.

An oxycodone postmortem database was created from 1243 solicited cases from Medical Examiner and Coroner (ME/C) offices in 23 states in the United States over the period from August 27, 1999, through January 17, 2002. The request for cases was specific to only those cases in which the ME/C opined that the death involved oxycodone. Each case was evaluated to determine the role of oxycodone and the specific drug product OxyContin tablets in the death. Oxycodone identification was based on toxicology testing, and OxyContin identification was based on evidence found at the scene, credible witness reports, or identification of tablets in gastrointestinal contents. A system of case categorization was developed for this study based on the Drug Abuse Warning Network (DAWN) system for reporting drug abuse mortality data in the United States, using the same standardized, well-understood terminology. Of the 1243 cases, 79 cases were incomplete and could not be evaluated. There were an additional 150 cases submitted in which oxycodone was not identified by the originating ME/C. Of the remaining 1014 cases, 919 (90.6%) were related to drug abuse, whereas 95 (9.4%) cases were categorized as not involving drug abuse. Only 30 (3.3%) of the drug abuse cases involved oxycodone as the single reported chemical entity; of these, 12 cases had OxyContin identified as a source of oxycodone. Of the 919 drug abuse cases, the vast majority (N = 889, 96.7%) were multiple drug abuse deaths in which there was at least one other plausible contributory drug in addition to oxycodone. The most prevalent drug combinations were oxycodone in combination with benzodiazepines, alcohol, cocaine, other narcotics, marijuana, or antidepressants. Using the DAWN definitions, drug abuse cases were further categorized as drug-induced or drug-related. A total of 851 (92.6%) cases met the criteria for classification as being drug-induced, and the remaining 68 (7.4%) cases were categorized as drug-related. Cause of death (COD) statements from the originating ME/C indicated a general recognition of the role of abuse of multiple drugs in causing fatalities. Approximately 70% of the 889 cases in the multiple-drug-induced categories were listed in the COD or contributing COD statements as multiple-drug deaths. A variety of terms were employed in the COD statements to indicate multiple drug involvement such as "polydrug toxicity", "polypharmacy", "multiple drug poisoning", and "polypharmaceutical overdose". The system for death classification employed in this study recognizes the problems inherent in COD attribution when multiple drugs are involved. Use of this new system for reporting mortality data in future studies involving opioids is recommended.

Adult↗

PubMed1990

Factors modifying the use of anaesthetic drugs in the elderly.

The elderly are forming an ever greater proportion of our hospital population. The process of ageing produces a gradual erosion of all the body's margins of safety coupled with a decreasing ability to adapt. This has significant effects on the physiological responses to the surgical and pharmacological trespass encountered during anaesthesia. In addition elderly people often suffer from multiple pathology and polypharmacy, both of which play important roles in the selection of the optimal anaesthetic regimen.

Aged↗

PubMed2002

Antipsychotic prescribing practices in Connecticut's public mental health system: rates of changing medications and prescribing styles.

We characterized prescribing in Connecticut's State public mental health system to assess the feasibility of implementing an evidence-based medication algorithm. Medication records for a random sample of outpatients with diagnoses of schizophrenia spectrum disorders showed prescribing patterns similar to the entire United States. The base rate of changing antipsychotic medications was moderate. Over half of patients received decanoate medications, polypharmacy was nontrivial, and there was variability in prescribing patterns across physicians. Caucasian patients were more likely to receive an atypical antipsychotic and less likely to have a decanoate medication, and Latino patients were less likely to change medications. Because the base rate of changing medications was moderate and a considerable proportion of patients were prescribed newer antipsychotic medications, introducing a research-derived medication algorithm with newer atypical antipsychotics as first line agents may fit well with current practice. Further, implementing such an algorithm may reduce racial and ethnic disparities in prescribing patterns.

Adult↗

PubMed2002

Antipsychotic prescribing practices in the Veterans Healthcare Administration--New York metropolitan region.

Most research literature concerning pharmacological treatments reports results from controlled clinical trials, which provide data critical to assess the efficacy of new treatments in research populations. Fewer studies examine how treatments are adopted in everyday practice settings, where comorbid disorders and environmental issues typically complicate patients' situations. In this study, we examine the evolution of antipsychotic prescribing practices in the New York region of the Veterans Healthcare Administration (VHA) from 1998 to 2000 using administrative data. Second generation antipsychotic medications are now prescribed more frequently than the older antipsychotic medications, with a concomitant increase in cost. Data show low rates of clozapine use, relatively high rates of polypharmacy, and intersite variation in prescribing practices. Additional research in everyday practice settings is needed to address clinical questions unlikely to be answered through traditional efficacy research and to examine reasons for intersite differences in prescribing patterns.

Adult↗

PubMed2005

Methotrexate-induced pancytopenia: serious and under-reported? Our experience of 25 cases in 5 years.

OBJECTIVE: To ascertain the extent of methotrexate (MTX)-related pancytopenia at the Norfolk and Norwich University Hospital (NNUH) between 1999 and 2004. METHODS: Patients were identified by a department database search, review of pharmacy records and personal communication. Pancytopenia was defined as white blood cell count (WBC) <3.5 x 10(9)/l, haemoglobin (Hb) <11 g/dl and platelet count <130 x 10(9)/l. Severe pancytopenia was defined as WBC <2.0 x 10(9)/l, Hb <10 g/dl and platelet count <50 x 10(9)/l. RESULTS: Twenty-five patients had MTX-induced pancytopenia. Eleven patients were taking folic acid and one folinic acid. The median dose of MTX was 12.5 mg weekly (interquartile range 5.625 mg) and median duration of treatment 36 months (interquartile range 40.5 months). The severity of pancytopenia correlated with the dose (P = 0.04). The numbers of patients with potential risk factors were: renal insufficiency, 8; pre-existing folate deficiency, 7; age >75 yr, 15; hypoalbuminaemia, 18; pre-existing infection with hip prosthesis, 1; possible drug interactions, 18; dosing errors, 1; and polypharmacy, 15. Pancytopenia was detected by routine blood monitoring in nine patients. There were seven deaths (28% mortality), five from sepsis and two from acute myeloid leukaemia. CONCLUSION: This is the largest reported individual case series of MTX-induced pancytopenia. With the increasing long-term use of MTX, it is important that patients be monitored for haematological side-effects as pancytopenia can be a late manifestation. Pharmacogenetics may hold the answer to predicting who is at risk of this potentially fatal complication of MTX.

Aged↗

PubMed1978

Drug interactions in rheumatoid disease--are they of any clinical importance?

Much of the literature on drug interactions over-emphasizes their importance. A review of the mechanisms of drug interactions and of the clinically important interactions involving drugs commonly used in rheumatology reveals that serious interactions are likely to be uncommon. A practical approach to this problem may be divided into three parts: 1. Be aware of the mechanisms of drug interactions as they may explain some unexpected finding occurring during drug treatment. 2. Remember that serious drug interactions are more likely to involve a drug which possesses a narrow therapeutic range (e.g. oral anticoagulants). 3. When indulging in polypharmacy attempt to ensure that such treatment has real benefits. This last point may be the most important for if it is proven that combined therapy has no advantages then the potential for drug interactions will be much reduced.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1992

Treatment of the neuroleptic-nonresponsive schizophrenic patient.

The treatment and management of neuroleptic-resistant schizophrenic patients, who comprise 5 to 25 percent of all patients with that diagnosis, are major problems for psychiatry. In addition, another large group of schizophrenic patients, perhaps 5 to 20 percent, are intolerant of therapeutic dosages of neuroleptic drugs because of extrapyramidal symptoms, including akathisia, parkinsonism, and tardive dyskinesia. Because about 60 percent of neuroleptic-resistant schizophrenic patients respond to clozapine and a large percentage of neuroleptic-intolerant patients are able to tolerate clozapine, it should be considered the treatment of choice for such patients until other therapies are proven to be superior. A trial of clozapine alone should usually be continued for up to 6 months before it is terminated or supplemental agents are tried. Plasma levels of clozapine may be useful to guide dosage. The major side effects of clozapine are granulocytopenia or agranulocytosis (1%-2%) and a dose-related increase in the incidence of generalized seizures. Psychosocial treatments such as education of the patient and the family about the nature of the illness, rehabilitation programs, social skills training, and assistance in housing are generally needed to obtain optimal benefit from clozapine, as with other somatic therapies. If clozapine is unavailable, unacceptable, or not tolerated, a variety of approaches may be employed to supplement typical antipsychotic drugs for patients who do not respond adequately to these agents alone. These include lithium; electroconvulsive therapy; carbamazepine or valproic acid; benzodiazepines; antidepressant drugs; reserpine; L-dopa and amphetamine; opioid drugs; calcium channel blockers; and miscellaneous other pharmacologic approaches. The evidence for the efficacy of these ancillary somatic therapies in treatment-resistant patients is relatively weak. Polypharmacy should be tried only for discrete periods and with clear goals. If these are not achieved, supplemental medications should be discontinued. Psychosurgery is not a recommended alternative at this time.

Antipsychotic Agents↗