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PubMed1990

Assessing seizure activity in mentally disabled adults.

Epilepsy occurs in about 30% of mentally disabled adults. With the closure of long-term care institutions and the move of patient care into the community, there is greater opportunity for nurses to provide care for disabled people in hospitals, clinics and other community settings. The ability to accurately assess seizure activity in these people is essential in order to provide the best possible treatment. This article discusses factors which complicate assessment: lack of verbal skills, attendant neurological deficits, polypharmacy, misdiagnoses and presumed noncompliance with diagnostic procedures. Practical nursing interventions and strategies to address this clinical problem are offered.

Adult↗

PubMed1996

Clinical advocacy for persons with epilepsy and mental retardation living in community-based programs.

There is a trend toward reducing the amount of antiepileptic drugs (AEDs) prescribed to persons with developmental disabilities and epilepsy who live in institutional settings. This trend is much less clear with persons who live in community-based settings. A significant percent (58%) of the author's past and current clinical caseload of community-based residents benefitted from AED reductions. An overview of AED usage of all individuals with mental retardation and epilepsy living in homes managed by one community-based vendor was conducted. With 52.5% of the residents taking AED polypharmacy, the assessment illustrates the need to provide clinical advocacy. The improvement in the quality of life is significant for many as evidenced by the three case studies provided. The benefits of clinical advocacy and improved health-related quality of life are discussed.

Activities of Daily Living↗

PubMedDate not supplied

Treating hypertension in the elderly.

Hypertension is highly prevalent in elderly individuals, the most rapidly growing segment of the US population. Epidemiologic studies have established that increased risk of cardiovascular disease is associated with elevated blood pressure. Treatment of hypertension in elderly patients significantly reduces their cardiovascular morbidity and mortality. However, antihypertensive therapy is often challenging in this patient population because of potential metabolic and physiologic alterations, multiple comorbidities, polypharmacy, and biologic variability. Drugs with a convenient dosing schedule, minimal side effects, and the ability to impact comorbid conditions are important considerations in the treatment of hypertension in the elderly.

Age Factors↗

PubMedDate not supplied

Rhabdomyolysis and statin therapy: relevance to the elderly.

A recent debate has emerged as to the risk-benefit ratio of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins). This debate has centered on the withdrawal of the HMG-CoA reductase inhibitor cerivastatin (Baycol). Its withdrawal was prompted by an unacceptably high rate of rhabdomyolysis associated with its use. The development of rhabdomyolysis in cerivastatin-treated patients surprised few, since myotoxicity is a class effect with HMG-CoA reductase inhibitors. What has sprung from the cerivastatin experience, though, is the concept of "guilt by association"; thus, other members of this class are now viewed in a similarly negative light. Such misgivings are understandable, but to a degree may be ill-advised, since differences exist in the risk and therefore the rate of rhabdomyolysis occurrence among the various HMG-CoA reductase inhibitors. In this regard, pravastatin and fluvastatin are least likely to provoke muscle cell damage, which, at least in part, relates to their not being metabolized by the cytochrome P-450 (CYP) 3A4 pathway. When muscle damage does occur with HMG-CoA reductase inhibitors, it is commonly the result of drug-drug interactions rather than a specific adverse response to HMG-CoA reductase inhibitor monotherapy. Such drug-drug interactions inevitably result in higher plasma concentrations of an HMG-CoA reductase inhibitor and thereby an increased risk of myotoxicity. A growing consensus supports an expanded use of HMG-CoA reductase inhibitors in elderly patients. Polypharmacy and altered drug metabolism both put the elderly patient at increased risk of myotoxicity when drugs in the HMG-CoA reductase inhibitor class are administered. Physicians must take many factors into account when selecting a member of the HMG-CoA reductase inhibitor class, particularly as relates to their use in the multiply medicated elderly patient.

Aged↗

PubMedDate not supplied

Heart failure in the elderly: strategies to optimize outpatient control and reduce hospitalizations.

Heart failure is a disorder that disproportionately affects the elderly, and over 50% of heart failure hospitalizations in the United States occur in persons over 75 years of age. Moreover, despite recent advances in heart failure therapy, optimal treatment of elderly patients remains undefined. In addition, heart failure management in older persons is often complicated by the presence of multiple comorbid conditions, polypharmacy, psychosocial and behavioral concerns, dietary issues, and economic considerations. As a result, management of heart failure in the elderly requires a coordinated, multidisciplinary approach, and a series of recent studies have documented the efficacy of heart failure disease management programs in reducing readmissions, enhancing medication and dietary compliance, and lowering cost of care. Ongoing studies will provide insights into the feasibility and effectiveness of implementing heart failure disease management programs on a population-wide basis, and on the effects of such programs on long-term clinical outcomes and costs.

Aged↗

PubMed1993

Peripheral benzodiazepine receptors in platelets of epileptic patients.

Tolerance to the anticonvulsant effect of benzodiazepines is likely to involve changes at the central benzodiazepine-GABA receptor complex. Peripheral benzodiazepine receptors (pBZRs), which can be measured in platelets, may also be involved. Using a binding assay with [3H]-PK 11195 as radioligand, pBZRs were assayed in platelets of patients taking a variety of antiepileptic drugs (AEDs). Comparisons were made with untreated patients. pBZR receptor density (mean +/- s.e. mean) was increased vs controls (8083 +/- 557 fmol mg-1 protein) in the platelets of patients taking a polypharmacy regime including the benzodiazepine clobazam (12661 +/- 1011 fmol mg-1 protein, P < 0.005) and also in those receiving sodium valproate as monotherapy (15003 +/- 1756 fmol mg-1 protein, P < 0.01). The significance of these findings is unclear, but the use of a specific pBZR antagonist may be a promising avenue for investigating the mechanism of BZ tolerance and its prevention.

Adolescent↗

PubMed2004

Potential for drug interactions involving cytochromes P450 2D6 and 3A4 on general adult psychiatric and functional elderly psychiatric wards.

AIMS: To assess the potential for interactions involving cytochromes P450 2D6 (CYP2D6) and 3A4 (CYP3A4) between drugs prescribed in a city in-patient psychiatric service. METHODS: Prescription information was obtained from all 236 patients in general adult wards and all 87 patients in functional elderly wards under a city psychiatric service. The frequencies with which combinations of drugs expected to interact via CYP2D6 or CYP3A4 were documented and compared between these two settings. RESULTS: All 2089 drug prescriptions, of which 1237 (59%) were administered, were analyzed. One hundred and seventy-two patients (73%) on adult wards and 59 (68%) on functional elderly wards were prescribed at least one drug metabolized by and/or inhibiting CYP2D6, the difference being nonsignificant (95% confidence interval on the difference -6.3%, 16.4%). Anticipated interactions from 62/82 CYP2D6-related combinations prescribed on adult wards (27/100 patients) and 19/30 prescribed to elderly patients (22/100 patients) were judged to be clinically important or potentially clinically important. The proportion of patients on functional elderly wards prescribed at least one drug interacting with CYP3A4 (87%) was significantly greater than that for patients on adult wards (57%, P < 0.001). The frequency of interactions involving CYP3A4 was significantly greater on functional elderly than adult wards (43/100 vs 22/100 patients, P < 0.025, 95% confidence interval on the difference 4, 38/100). CONCLUSIONS: Our findings confirm extensive polypharmacy on general adult psychiatric and functional elderly psychiatric wards. A substantial proportion of patients were receiving combinations of drugs that interact with CYP2D6 and/or CYP3A4, many of which are known to produce clinically important interactions. Doctors practising in old age psychiatry should be aware that patients on functional elderly wards are at increased risk of clinically important CYP3A4 interactions. Psychiatrists should consider the pharmacokinetic implications of drugs prescribed for use 'as needed', because of the potential for unpredictable interactions.

Adolescent↗

PubMed2004

Influence of socioeconomic status on the quality of prescribing in the elderly -- a population based study.

AIMS: To compare the quantity and quality of prescribing, using prescribing indicators, between the relatively deprived and the relatively affluent patients over 70 years old in primary care. METHODS: We examined the General Medical Services (GMS) scheme prescribing data for the Eastern region in Ireland for all patients aged 70 years or more (n = 95 055) during July 2001-December 2002. Prescribing indicators applied to the prescription data to evaluate drugs prescribed to each patient were classified as: (1) descriptive, e.g. number of drug items/patient; (2) indicators assessing potentially harmful prescribing; (3) evidence-based indicators, e.g. secondary prevention therapy in those with ischaemic heart disease (IHD). Results are expressed as odds ratio (OR) and 95% confidence intervals for comparison of prescribing between the relatively deprived and affluent cohorts, adjusted for age and gender (CI) using logistic regression analysis. RESULTS: The relatively deprived cohort was more likely to receive a greater number of drugs (5.2 vs. 4.5, P < 0.0001), more generic products (P = 0.01) and be exposed to major polypharmacy (> or = five drugs) compared with monotherapy (OR = 1.58; 95% CI = 1.52,1.64, P < 0.0001). They were more likely to receive potentially harmful drugs such as cerebral vasodilators (OR = 1.52; 1.38,1.69), long-acting sulphonylurea (OR = 1.43; 1.20,1.72), potentially interacting agents such as angiotensin converting enzyme (ACE) inhibitor and potassium sparing diuretic (OR = 1.78; 1.48,2.15). In terms of evidence-based prescribing, the relatively deprived cohort with IHD was less likely to receive secondary prevention therapies such as statins (OR = 0.82; 0.74, 0.90) and beta blockers (OR = 0.85; 0.77,0.93). CONCLUSIONS: These results show that suboptimal prescribing is more prevalent among the relatively deprived cohort and suggests the differences observed in the quality of prescribing between these patient groups may be related to their socioeconomic status.

Aged↗

PubMed2005

Concomitant use of analgesics and psychotropics in home-dwelling elderly people-Kuopio 75 + study.

AIMS: To investigate the extent of concomitant use of analgesic and psychotropic medicines among home-dwelling elderly people aged at least 75 years in Finland. METHODS: This was a population-based study in Finland, performed as part of Kuopio 75 + study focusing on the clinical epidemiology of diseases, medication and functional capacity. A random sample of 700 persons was drawn from the total population of the city of Kuopio, eastern Finland, aged 75 years on January 1, 1998 (n = 4518). Ninety-nine persons could not be examined and 78 were living in long-term institutions, so that the number of home-dwelling elderly persons amounted to 523. A trained nurse interviewed the participants about their use of medicines, and a geriatrician examined their overall physical and mental status. Dementia and depression were diagnosed according to the DSM IV criteria. Both regular and irregular prescribed and nonprescribed drug use was recorded. RESULTS: Every fourth elderly person (27.2%) used analgesics and psychotropics concomitantly, this use becoming twice as common with advancing age (19.6% in the age group 75-79 years, 38.2% among the oldest, aged 85 + years). Concomitant use of psychotropics and opioids also became more common with increasing age (2.8% in age group 75-79 years and 9.6% in the oldest group, aged 85 + years). The use of opioids was nearly twice as common among concomitant users (19.7%) than among those using only analgesics (11.3%). Concomitant users suffered from interfering daily pain and daily pain at rest more commonly than nonusers of analgesics. Depression, sleeping problems and polypharmacy were more common among the concomitant users, who had also had more hip fractures than the rest. CONCLUSIONS: Concomitant use of analgesics and psychotropics becomes more common with advancing age and is a potential risk factor for adverse drug effects.

Age Factors↗

PubMed2005

Oral hygiene care for residents with dementia: a literature review.

AIM: This paper presents a literature review of oral hygiene care for adults with dementia in residential aged care facilities, including evidence for: (1) prevalence, incidence, experiences and increments of oral diseases; (2) use of assessment tools to evaluate residents' oral health; (3) preventive oral hygiene care strategies; and (4) provision of dental treatment. BACKGROUND: The impact of dementia on residential care is ever-increasing and regular oral hygiene care provision is challenging for cognitively impaired residents. Although an abundance of oral hygiene care recommendations for older people have been published, the supporting evidence has not been clearly delineated. METHODS: A review was conducted of English language publications (1980-2002), using a two-step approach (keyword electronic database search, supplemented with secondary search of cited references). All 306 selected articles were critically reviewed and systematically categorized. RESULTS: Evidence confirmed clinicians' observations of poor oral health in older residents with dementia. Possible risk factors identified were: salivary dysfunction, polypharmacy, medical conditions, swallowing and dietary problems, functional dependence, oral hygiene care assistance and poor use of dental care. One comprehensive, reliable and validated oral assessment screening tool for residents with dementia had been published. Expert opinion indicated that oral assessment screening by staff and a dentist would be ideal at admission and regularly thereafter. Clinicians and researchers suggested that oral hygiene care strategies were effective in preventing oral diseases and appropriate for residents with dementia. CONCLUSION: These literature review findings supported the use of oral assessment screening tools by staff and efficacious preventive oral hygiene care strategies/products for adults with dementia in residential care facilities. Further research with this population is needed to develop and validate oral assessment tools and staff education programmes, trial preventive oral hygiene care strategies/products and trial dementia-focused behaviour management and communication strategies.

Aged↗

PubMed1986

The effect of a specialist clinic with pharmacist involvement on the management of epilepsy in paediatric patients.

At the request of the consultant, a pharmacist attended the paediatric out-patient neurology clinic held at Ga-Rankuwa Hospital, from June 1984. After 6 months of this 'team' approach, its effect on patient care was evaluated. The study consisted of a retrospective survey of approximately 100 patient-visits before and after the establishment of the specialist clinic. Patient medication details and frequency of fits were analysed by a microcomputer. There was an increase in the number of patients seen per session. The results also showed that polypharmacy, dosing frequency and average dose per day were reduced under the new arrangement, whilst disease control, i.e. fit frequency, was no worse. The overall result has been to rationalize and improve anticonvulsant drug therapy at this clinic.

Ambulatory Care↗

PubMed1992

Influence of age and co-medication on steady-state phenobarbital serum level-dose ratios in Japanese paediatric patients.

The effects of age and co-medication on steady-state phenobarbital (PB) level-dose (L/D) ratios were evaluated retrospectively in 539 paediatric patients. The PB L/D ratio increased significantly with age up to 15 years. Associated anti-epileptic therapy affected the PB L/D ratio, which was significantly increased in patients on polypharmacy as compared to patients on monopharmacy. Therefore, routine monitoring of PB serum levels is extremely useful, particularly in the paediatric age group, and in patients who require associated anti-epileptic medication.

Adolescent↗

PubMed2005

Use of moxonidine in elderly patients with resistant hypertension.

BACKGROUND: Treatment of hypertension in the elderly people reduces the risk of cardiovascular and cerebrovascular events. Effective treatment often will require the use of two or more antihypertensive agents. Elderly people are at increased risk of adverse events from medication because of physiological changes in pharmacokinetics and pharmacodynamics, polypharmacy and drug interactions. They might not tolerate conventional add-on regimens of antihypertensives as a result. OBJECTIVE: To investigate the use of the I1-imidazoline receptor agonist moxonidine as an 'add-on' agent in elderly patients with resistant hypertension. METHODS: We investigated the safety and efficacy of moxonidine (200-400 microg) in a group of elderly patients whose blood pressure (BP) control remained poor despite treatment with two or more antihypertensives. BP was assessed by ambulatory BP monitoring with Spacelabs oscillometric equipment (Model 90207) before and after 6 weeks of treatment with moxonidine used as an 'add-on' agent with the patients normal medication. RESULTS: Following treatment with moxonidine, the mean daytime systolic BP fell from 169.2 to 153.8 mmHg, a significant reduction of 15.4 +/- 8.9 mmHg (P = 0.003). The mean daytime diastolic BP fell from 91.6 to 84.2 mmHg, a reduction of 7.4 +/- 5.8 mmHg (P = 0.017). For the night-time readings, the systolic BP fell from 151.1 to 141.2 mmHg, a reduction of 9.3 +/- 9.3 mmHg (P = 0.05). The corresponding diastolic fall in BP was not significant (77.9-74.7 mmHg). The 24 h-readings showed a significant reduction in the mean systolic BP from 163.0 to 148.6 mmHg (P = 0.004). The mean diastolic BP also fell significantly from 87.2 to 80.2 mmHg (P = 0.013). Clinical BP readings also showed a significant reduction from 195.9 +/- 19.6 to 174 +/- 17.8 mmHg (P = 0.002) and 103.6 +/- 9.5 to 99.0 +/- 12.4 mmHg (P = 0.013) for systolic and diastolic readings respectively. Moxonidine was well tolerated in 11 of the14 patients. CONCLUSION: These results suggest that moxonidine might have a place as an 'add-on' treatment in elderly patients whose hypertension is poorly controlled despite treatment with two or more antihypertensive agents.

Aged↗

PubMed1994

Comparison of community and institutional prescription of antiepileptic drugs for individuals with learning disabilities.

The use of antiepileptic agents for individuals with learning disabilities (mental handicap) resident both within National Health Service facilities and the community was surveyed in the UK. There was no difference in rates of polypharmacy, but there were significant differences in choice of antiepileptic agent. In particular, individuals resident in the community were more likely to be in receipt of phenytoin, primidone and phenobarbitone, which are particularly recognized as producing adverse effects on cognition and behaviour.

Adult↗

PubMed2005

Topiramate in long-term treatment of epilepsy in the intellectually disabled.

BACKGROUND: To study the effectiveness of topiramate (TPM) in refractory epilepsy in patients who have intellectual disability (ID). METHODS: A representative population sample of 57 patients with ID (age range 2-61, mean 32.8) was administered add-on TPM for drug-refractory epilepsy. RESULTS: Seizure freedom for at least for 6 months was attained by 10 (17%), and seizure reduction of > or = 50% by further 26 (46%). Less than 50% decrease in seizure frequency was found in 16 (29%). TPM was more efficacious in localisation-related than in generalised epilepsies (81% vs. 50%, P=0.019). An at least 50% decrease in seizure frequency was achieved by patients with temporal lobe epilepsy in 100%, continuous spike-waves during sleep syndrome in 75%, Lennox-Gastaut syndrome in 52%, and those with infantile spasms in 25% of cases. As great decrease in seizure frequency was found in most patients with cortical dysplasia (83%), acquired encephalopathy with mesial temporal sclerosis (MTS) (75%), and genetic disease associated with MTS (66%). Adverse effects occurred in 10% including two (3%) with seizure aggravation and three (5%) necessitating discontinuation. CONCLUSION: TPM is an effective antiepileptic drug which is of value in treating people with seizures that are resistant to other antiepileptic medication. As a broad-spectrum drug it may substitute for polypharmacy and, at the same time decrease adverse effects and costs of therapy.

Adult↗

PubMed2005

A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies.

CONTEXT: Patient safety currently receives only scant attention in most residency curricula. Safety is a subject that transcends the US Accreditation Council for Graduate Medical Education's 6 core competencies. OBJECTIVE: To design and implement a new patient safety curriculum in collaboration with the Schools of Nursing and Pharmacy, in such a way as to address all 6 competencies. SETTING AND PARTICIPANTS: The curriculum applies to a university-based family medicine residency programme with 45 residents at 5 sites, including urban, suburban and rural sites. CURRICULUM DESIGN: The curriculum includes introductory workshops for faculty and residents, a series of didactic courses, individual portfolios and a series of small group exercises including chart reviews, case presentations and a longitudinal quality improvement project. The activities are run by a multidisciplinary team. OUTCOME MEASURES: Main outcome measures include assessment of resident performance in curriculum activities and in an annual objective structured clinical examination (OSCE) that includes standardised patient interviews, simulations and a written examination. Programme evaluation will include comparison of OSCE performance with that at a neighbouring residency. RESULTS: Residents identified safety problems and system-based solutions using a safety journal. Cases of polypharmacy were identified using journals and chart reviews, and medication changes proposed and discussed. At resident practice sites, residents identified safety priorities based on a staff survey and proposed system-based solutions. Results of the OSCE will be presented elsewhere. CONCLUSIONS: A new patient safety curriculum was successfully introduced into a family medicine residency. The curriculum integrates patient safety into residents' daily activities and incorporates input from the disciplines of nursing and pharmacy so as to help build more effective clinical teams and inculcate a culture of safety.

Clinical Competence↗

PubMed2005

Collaborative care needs and preferences of primary care patients with multimorbidity.

OBJECTIVE To explore the collaborative care needs and preferences in primary care patients with multiple chronic illnesses. DESIGN Focus groups utilizing a series of open-ended questions elicited self-identified problems, experiences in communicating with providers, self-management needs, and preferences for monitoring and follow-up. Responses were organized and interpreted in light of the essential elements of collaborative care for chronic illness. SETTING AND PARTICIPANTS Sixty patients having two or more chronic illnesses at eight geographically dispersed primary care clinics within the Veterans Health Administration in the United States. RESULTS Identified problems included poor functioning, negative psychological reactions, negative effects on relationships and interference with work or leisure. Polypharmacy was a major concern. Problematic interactions with providers and the health care system were also mentioned, often in relation to specialty care and included incidents in which providers had ignored concerns or provided conflicting advice. Most participants, however, expressed overall satisfaction with their care and appreciation of their primary care physicians. Knowledge and skills deficits interfered with self-management. Participants were willing to use technology for monitoring or educational purposes if it did not preclude human contact, and were receptive to non-physician providers as long as they were used to augment, not eliminate, a physician's care. CONCLUSIONS Findings are consistent with the basic tenets of patient-centred, collaborative care, and suggested that health care can be organized and delivered to meet the complex needs of patients with multimorbidity.

Chronic Disease↗

PubMed1997

Health status, treatment and drug use in rural Bangladesh: a case study of a village.

In Bangladesh, the government healthcare system remains a very minor source of health care for rural households. The availability of registered physicians is scare in rural areas, and the people, the majority of whom are underweight as indicated by body mass index measurement have to depend on pharmacy salespersons, quacks and herbal or spiritual healers. Unlike Australia, almost every pharmacy salesperson illegally recommends and sells prescription medicines. In addition, there are also unqualified village 'doctors' who do not own a pharmacy shop but provide written prescriptions. However, the treatments provided by these village 'doctors' remain open to question, with instances of maltreatment or inadequate treatment. The treatments are mostly symptomatic and polypharmacy is common, with antibiotics and vitamins prescribed widely. On the other hand, rural people sometimes do not buy all the drugs that are prescribed for them, partly because of financial constraint. In addition, self-medication is common. While family planning and immunisation are slowly becoming popular among rural families, general health knowledge is still poor. Public healthcare campaigns as well as proper training for the rural prescribers could be helpful in improving the present poor rural healthcare system.

Adolescent↗