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PubMed1995

Psychotropic use among older residents of board and care facilities.

OBJECTIVE: To describe patterns of psychotropic use as well as clinically relevant and concurrent nonpsychotropic use among older residents of board and care facilities in 10 states. METHODS: Weighted use rates were based on data from a sample of 2054 residents aged 65 and older from 410 facilities in 10 states, drawn via a complex, multistage sampling design. Data, including drug name, use frequency, and PRN use, were collected on all drugs taken by the resident during a 7-day period. During face-to-face interviews with residents and/or proxies, data were also collected on resident characteristics. SUBJECTS: The majority of subjects were female, white, and widowed. Average age was 82 years. Approximately 25% had a current mental or emotional condition, and 8% had been hospitalized for a psychiatric condition during the year before admission. More than half needed help with at least one activity of daily living. Forty percent had moderate or severe cognitive impairment, and 18% had received mental health care during the previous year. ANALYSES: Weighted descriptive analyses were performed with Software for Survey Data Analysis (SUDAAN), which accounts for the complex, multistage sampling design. RESULTS: Approximately 35% of the older residents used at least one psychoactive agent, with 30% of psychotropic users receiving two to four different psychotropic medications. Use rates decline with age, for psychotropics overall and for therapeutic classes. Results revealed potentially problematic polypharmacy in relation to drug duplication within therapeutic classes, use of multiple psychotropics across classes, and concurrent nonpsychotropic use. CONCLUSIONS: Compared with community-dwelling older adults, this study revealed high psychotropic use rates among older board and care facility residents. Overall, our results suggest that serious consideration be given to the apparent need for systematic drug utilization review, a potentially useful program that is mandated in other settings.

Aged↗

PubMed1995

Vitamin D deficiency in older people.

Because of changes that occur with aging, older people with any other risk factors for vitamin D deficiency are likely to have inadequate stores of this vitamin. The consequences of vitamin D deficiency are likely to be losses in bone, strength, and function and the development of pain. Many questions remain regarding screening, prevention, and treatment of vitamin D deficiency. Supplementation may be unnecessary in most healthy, ambulatory seniors. Excessive supplementation in this group may lead to vitamin D toxicity. There does seem to be a role for supplementation in homebound older people who will not get adequate vitamin D from sunlight exposure. This population is at particular risk of developing vitamin D deficiency. Issues such as inadequate diet, physiologic changes with aging, polypharmacy, and diseases that interfere with vitamin D metabolism contribute to this risk. In such circumstances, a recommendation of 800 IU per day is reasonable. An alternative to daily dosing is a single oral dose of 100,000 IU of vitamin D (ergocalciferol or cholecalciferol) every 3 to 6 months. A simple maneuver is for geriatricians, who see many chronically ill patients with low vitamin D stores (who are likely to be seen in the office every 3 to 6 months), to administer vitamin D during the office visits. These dosing schedules have not been associated with toxicity and can be considered safe in homebound (sunlight-deprived) older adults.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Distribution↗

PubMed1996

Rehabilitation of the older lower limb amputee: a brief review.

OBJECTIVE: To review outcomes, over the last 25 to 30 years, of prosthetic rehabilitation in the older patient with a major lower limb amputation. DESIGN: Literature review of articles and reports about lower limb amputation, using key words elderly amputee rehabilitation, and lower limb amputation, through a computerized Medline Search. CONCLUSIONS: Age alone should not determine prosthetic rehabilitation. Comorbidities and general health are important determinants. The more proximal the amputation, the more energy is demanded from the cardiovascular and pulmonary systems for prosthetic gait. Changes in surgical technique and revascularization procedures have allowed preservation of the knee, which decreases energy demands and allows more older patients a chance to undergo rehabilitation for ambulation. Although the ratio of below knee (transtibial) amputations to above knee (transfemoral) amputations has increased, overall postsurgical mortality (10-30%), long term survival (40-50%@2 years, 30-40%@5 years), and risk of loss of the contralateral leg (15-20%@2 years) has not changed significantly since the 1960s. Despite the lack of improvement in survival as a result of the systemic vascular disease, the older patient can benefit from rehabilitation efforts with goals of prosthetic ambulation or simply cosmesis. The shortened longevity emphasizes the need for timely rehabilitation to enhance the quality of the remaining years. The geriatrician can add to the presurgical care and preprosthetic phase of rehabilitation by attention to the problems common to the older patient, i.e., multiple comorbidities, polypharmacy, immobility, and depression. Postoperatively, early mobilization is crucial to avoid the deleterious effects of immobility in the older person. Further investigations into the psychosocial issues and cost benefits of limb loss and prosthetic rehabilitation are needed. In addition, comparison of the various rehabilitation protocols and the impact of cardiac resting before rehabilitation are needed.

Age Factors↗

PubMed1999

Chronic care clinics: a randomized controlled trial of a new model of primary care for frail older adults.

OBJECTIVE: To determine whether a new model of primary care, Chronic Care Clinics, can improve outcomes of common geriatric syndromes (urinary incontinence, falls, depressive symptoms, high risk medications, functional impairment) in frail older adults. DESIGN: Randomized controlled trial with 24 months of follow-up. Physician practices were randomized either to the Chronic Care Clinics intervention or to usual care. SETTING: Nine primary care physician practices that comprise an ambulatory clinic in a large staff-model HMO in western Washington State. PARTICIPANTS: Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline. INTERVENTION: Intervention practices (5 physicians, 96 patients) held half-day Chronic Care Clinics every 3 to 4 months. These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications; and a patient self-management/support group. Control practices (4 physicians, 73 patients) received usual care. MEASUREMENTS: Changes in self-reported urinary incontinence, frequency of falls, depressive symptoms, physical function, and satisfaction were analyzed using an intention-to-treat analysis adjusted for baseline differences, covariates, and practice-level variation. Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed. RESULTS: After 24 months, no significant improvements in frequency of incontinence, proportion with falls, depression scores, physical function scores, or prescriptions for high risk medications were demonstrated. Costs of medical care including frequency of hospitalization, hospital days, emergency and ambulatory visits, and total costs of care were not significantly different between intervention and control groups. A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients (40.0% vs 25.3%, P = .10). CONCLUSIONS: Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics, improved outcomes for selected geriatric syndromes were not demonstrated. These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system.

Aged↗

PubMed2004

The "nondipper" elderly: a clinical entity or a bias?

OBJECTIVES: To determine the prevalence of nondipper (ND) blood pressure profile in the elderly and to ascertain whether the ND pattern of ambulatory blood pressure in the elderly is an artifact or represents a specific clinical entity. DESIGN: Cross-sectional, observational study. SETTING: Cardiovascular diagnostic center, division of geriatrics, secondary care, institutional practice. PARTICIPANTS: Sixty-five consecutive community-dwelling elderly hypertensive patients referred to the cardiovascular center. MEASUREMENTS: The patients underwent actigraphy and ambulatory blood pressure monitoring and completed a sleep assessment questionnaire. Patients were divided based on the night-time decrease in blood pressure (>10%: "dippers" (n=19); <10%: "NDs" (n=46)). RESULTS: Nondippers displayed poorer quality of sleep, as demonstrated objectively by actigraphic data; they obtained a higher mean score+/-standard deviation on the sleep questionnaire (4.6+/-2.9 vs 3.0+/-1.1, P=.030) and were taking more benzodiazepines (33.1% vs 10.7%, P=.035), indicating that their usual sleep quality was worse than that of dippers. Multivariate analysis showed a strong correlation between nondipper profile and quality of sleep and also with comorbidity, total number of drugs being taken, and pulse pressure. CONCLUSION: Actigraphy demonstrates impaired sleep in the nondipper elderly. Nevertheless, the nondipping pattern seems independent of the discomfort of cuff-inflation during the night and occurs in association with higher comorbidity and polypharmacy; therefore, it cannot be considered a "bias," but is related to detrimental clinical conditions that should be studied in depth.

Aged↗

PubMed2003

Trends and treatment of heart failure developing after acute myocardial infarction.

The development of heart failure and/or left ventricular systolic dysfunction following acute myocardial infarction remains prevalent despite improvements in the diagnosis and management over the past decades. Although transient in some cases, the majority of these patients continue to carry a substantially higher mortality risk. New data on the benefits of eplerenone and carvedilol from large clinical trials have added to the complexity of polypharmacy in this patient subgroup, although aggressive medical strategies to prevent or reverse infarct-related left ventricular remodeling remains the most effective method to save lives and prevent disabilities.

Adrenergic beta-Antagonists↗

PubMed2000

Influence of Helicobacter pylori eradication therapy on 13C aminopyrine breath test: comparison among omeprazole-, lansoprazole-, or pantoprazole-containing regimens.

OBJECTIVE: Proton pump inhibitors and antimicrobial agents are widely used to eradicate Helicobacter pylori (H. pylori) infection. In the general population the prevalence of infection and of polypharmacy increases the possibility of drug-drug interactions during H. pylori eradication therapy. The purpose of the present study was to assess the prevalence, degree, and clinical relevance of metabolic interference with the cytochrome P450 enzymatic system occurring during 1 wk of administration of omeprazole, lansoprazole, or pantoprazole followed by the association of clarithromycin and metronidazole for another week. The 13C aminopyrine breath test (ABT) was chosen to screen for possible interactions. METHODS: We studied 30 patients referred to our Unit for H. pylori eradication therapy. They were randomized to receive either omeprazole (20 mg b.i.d.), lansoprazole (30 mg b.i.d.), or pantoprazole (40 mg b.i.d.) for 2 wk. During the second week clarithromycin (250 mg b.i.d.) and metronidazole (500 mg b.i.d.) were added. ABT was performed before, and at the end of the first and second week of therapy. Percentage of the administered dose of 13C recovered per hour at the peak (percent 13C dose/h at the peak) and cumulative percentage of administered dose of 13C recovered over time at 120 min (percent 13C dose cum120) were the ABT evaluated parameters. RESULTS: At baseline all patients showed a normal liver function. In individual patients during treatment we observed various liver metabolic interactions both as inhibition and induction, as well as after the first and the second week of therapy. However, mean modifications of the ABT parameters during the 2 weeks of therapy were not statistically significant compared to baseline values. None of the patients who had ABT variations complained of side effects. CONCLUSIONS: H. pylori eradication therapy interferes with cytochrome P450-dependent liver metabolic activity. However, the clinical relevance of these metabolic interactions is not yet apparent, and further investigation is needed. H. pylori eradication therapy appears safe, but these interactions should be considered in the choice of proton pump inhibitor and antimicrobial agents.

2-Pyridinylmethylsulfinylbenzimidazoles↗

PubMed2005

Avoiding the vicious cycle of prolonged opioid use in Crohn's disease.

The decision to use opioid analgesics in the management of chronic pain in patients with Crohn's disease is a complex one. Little is known about the effects of long-term high-dose opioids on cognitive function or risk of opioid addiction. At higher doses, opioids affect the gastrointestinal tract adversely and may result in perturbations of the endocrine and immune systems. Distinguishing functional gastrointestinal symptoms from inflammatory symptoms can further complicate this issue. Cross and colleagues have attempted in a retrospective cross-sectional study to identify factors which may predict narcotic use in patients with Crohn's disease. Increased disease activity, polypharmacy (particularly with neuropsychiatric drugs) and cigarette smoking were found to be independent predictors of chronic narcotic use in these patients. Future research in this area is greatly needed to improve patient care. In patients with Crohn's disease, caution should be exercised when it comes to the liberal use of narcotics.

Analgesics, Opioid↗

PubMed1979

Prescribing patterns in psychiatric hospitals in Israel.

A survey conducted by pharmacists working in four psychiatric hospitals in Israel to assess the prescribing of psychotropic drugs revealed that polypharmacy was common: patients were receiving up to 11 different drugs and up to six different psychotropic drugs. The average number of psychotropic drugs per patient was two. The most popular combinations of drugs used were; one containing an antipsychotic drug(s) and an antiparkinson drug(s) and the other was a combination of more than one antipsychotic agent. Up to 30 doses per day were taken orally by one patient. Drugs that could have easily been administered on a once-a-day time schedule were often administered several times a day. Differences in prescribing patterns in the various hospitals and often times on different wards of the same institution could more easily be attributed to different educational backgrounds, habits and personal beliefs and perhaps the physician's experience as well, rather than to the types of patients treated.

Adolescent↗

PubMed1981

Depressions in schizophrenia: some observations on prevalence, etiology, and treatment.

The results suggest that not only is depression a common symptom or syndrome in all stages of schizophrenia, but it is common even in the absence of treatment. However, there are a number of reasons for thinking that a proportion of patients on drugs may well suffer from drug related depressions, possibly 7.5-12.5 per cent. A difference in the effect upon mood, in the acute schizophrenic state, between flupenthixol and fluphenazine, has already been suggested (Johnson & Malik (1975)). Current research (Johnson (1976, 1979)) suggests that regular neuroleptic maintenance therapy is necessary for many years, certainly for more than four years following the most recent relapse. It is therefore of particular importance to concern ourselves with all potential side-effects such as extrapyramidal symptoms, weight gain (Johnson & Breen (1979)) an tardive dyskinesia (Gibson (1978)), and to keep the patients on personalised dose regimes which can frequently be reduced with time, particularly over the first two years of treatment (Johnson (1975, 1977)). WE must equally be on our guard against unnecessary polypharmacy which ultimately increases the risks for an already greatly disadvantaged patient.

Antidepressive Agents↗

PubMed1983

Psychotropic drug prescription in Nigeria.

A study of prescribing practice in three psychiatric institutions in Nigeria revealed high frequency of polypharmacy liberal routine use of antiparkinsonian agents and daily multiple administration of drugs. In the treatment of depression and schizophrenia older and better known oral neuroleptics were preferred to newer ones, but there was apparent tendency for depressives to be under-treated and long-acting depot preparations were seldom administered to schizophrenics. Several aspects of drug use were similar to those observed elsewhere, particularly in the Anglo-American practice - an observation presumed explicable in terms of common psychiatry training background. The need for clinicians to comply with acceptable pharmacokinetic principles of drug treatment is stressed.

Adolescent↗

PubMed1985

Mianserin is better tolerated and more effective in depression than a nomifensine-clobazam combination: a double-blind study.

Patients suffering from depression (mostly depressive neurosis) were admitted to a double-blind study which compared the efficacy of a combination of nomifensine and clobazam with mianserin. Therapeutic efficacy was evaluated on the Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Clinical Global Impression Scale, physician's assessments, Global Improvement and Treatment Emergent Symptom Scale for side-effects. Assessments were made before admission to the trial and on days 3, 7, 14 and 21. Forty patients were randomly allocated to two treatment groups. A case is made against polypharmacy and in particular against the use of benzodiazepine combinations in depression. Nineteen patients on nomifensine-clobazam and 14 on mianserin completed the three-week trial. At 7, 14 and 21 days, the Hamilton Depression Rating Scale (HDRS) total scores were significantly improved for mianserin when compared with nomifensine-clobazam. Similarly, at 7 and 14 days the Hamilton Anxiety Rating Scale (HARS) total scores were significantly better for mianserin than for the nomifensine-clobazam combination. There were also significant improvements for mianserin on the HDRS sub-scales of anxiety somatization, cognitive disturbance and sleep disturbance. There were no significant differences for HDRS somatic symptoms between treatment groups. Drowsiness was the most common side-effect in both groups. The incidence of total side-effects was 74% for nomifensine-clobazam and 71% for the mianserin group.

Adolescent↗

PubMed1996

Treatment of manic episodes: zuclopenthixol and clonazepam versus lithium and clonazepam.

For the treatment of acute mania, no single drug is sufficiently effective in daily clinical routine for all patients. Drug combinations are often prescribed but poorly investigated. The present study examined whether a treatment with a neuroleptic drug (zuclopenthixol) combined with a benzodiazepine (clonazepam) was superior to a treatment with lithium and the same benzodiazepine (lithium citrate and clonazepam). Twenty-eight hospitalized patients with a DSM-III-R manic episode were included, randomized to fixed drug doses and observed up to 28 days. Degree of mania, side effects and patients satisfaction with the treatment were registered. Approximately two thirds of the patients improved fully or partially on both drug combinations. Furthermore no statistically significant differences were found regarding acceptance and tolerance of the two drug combinations. The present drug combination are only two among several which deserve a thorough examination in order to prevent a random polypharmacy for treatment of mania.

Administration, Oral↗

PubMed2006

Maintenance antipsychotic medication patterns in outpatient schizophrenia patients: a naturalistic cohort study.

OBJECTIVE: Newer antipsychotics are increasingly used in schizophrenia maintenance. The UK change has been slow with little known on switching patterns. We aimed to investigate antipsychotic prescribing patterns in schizophrenia patients. METHOD: A naturalistic six-site cohort sample of 600 patients were interviewed by researchers at 6-monthly intervals for 2 years to record their clinical and social functioning; use of services and medication for the preceding 6 months was obtained by structured extraction from clinical case notes. RESULTS: Alterations in antipsychotic medication were frequent in this group, mainly during periods of inpatient care. Atypical prescribing increased steadily, though slowly, across the period. Polypharmacy was less than anticipated. CONCLUSION: Inpatient care remains the main forum for switching of antipsychotics. The UK maintains a slow shift to atypical antipsychotics.

Adult↗

PubMed2004

Oral mucosal and osseous disorders in frail elders.

OBJECTIVE: This paper reviews the implications of frailty for oral health in old age due to the incidence of oral pathoses following on mucosal atrophy, tooth loss, trauma from dentures, polypharmacy, malnutrition, salivary disorders, degeneration of jawbone and cancer. BACKGROUND: Frailty as a condition of old age occurs when elders have energy levels below a critical threshold, or when the social or cultural environment is limited. RESULTS: Frail elders are particularly vulnerable to pathoses, but not simply because of old age per se. Oral diseases accompanying frailty are due to a complicated mixture of biopsychosocial changes that accompany old age. CONCLUSIONS: Management of oral mucosal and osseous disorders in frail elders requires an understanding of the changes that occur with advancing age.

Aged↗

PubMed2007

Metabolic drug interactions with newer antipsychotics: a comparative review.

Newer antipsychotics introduced in clinical practice in recent years include clozapine, risperidone, olanzapine, quetiapine, sertindole, ziprasidone, aripiprazole and amisulpride. These agents are subject to drug-drug interactions with other psychotropic agents or with medications used in the treatment of concomitant physical illnesses. Most pharmacokinetic interactions with newer antipsychotics occur at the metabolic level and usually involve changes in the activity of the major drug-metabolizing enzymes involved in their biotransformation, i.e. the cytochrome P450 (CYP) monooxygenases and/or uridine diphosphate-glucuronosyltransferases (UGT). Clozapine is metabolized primarily by CYP1A2, with additional contribution by other CYP isoforms. Risperidone is metabolized primarily by CYP2D6 and, to a lesser extent, CYP3A4. Olanzapine undergoes both direct conjugation and CYP1A2-mediated oxidation. Quetiapine is metabolized by CYP3A4, while sertindole and aripiprazole are metabolized by CYP2D6 and CYP3A4. Ziprasidone pathways include aldehyde oxidase-mediated reduction and CYP3A4-mediated oxidation. Amisulpride is primarily excreted in the urine and undergoes relatively little metabolism. While novel antipsychotics are unlikely to interfere with the elimination of other drugs, co-administration of inhibitors or inducers of the major enzymes responsible for their metabolism may modify their plasma concentrations, leading to potentially significant effects. Most documented metabolic interactions involve antidepressant and anti-epileptic drugs. Of a particular clinical significance is the interaction between fluvoxamine, a potent CYP1A2 inhibitor, and clozapine. Differences in the interaction potential among the novel antipsychotics currently available may be predicted based on their metabolic pathways. The clinical relevance of these interactions should be interpreted in relation to the relative width of their therapeutic index. Avoidance of unnecessary polypharmacy, knowledge of the interaction profiles of individual agents, and careful individualization of dosage based on close evaluation of clinical response and, possibly, plasma drug concentrations are essential to prevent and minimize potentially adverse drug interactions in patients receiving newer antipsychotics.

Antipsychotic Agents↗

PubMed1991

Medication-taking by the frail elderly in two ethnic groups.

A complex and dangerous area of medical intervention with the elderly population is drug therapy. Although drugs have contributed to the well-being of many older persons, some elderly individuals are at risk due to polypharmacy and age-related factors. The purpose of this preliminary study was to investigate the medication-taking behaviors of two ethnic groups of noninstitutionalized frail elderly individuals. The findings indicate that these individuals may be at risk for harm due to their medication-taking practices. Healthcare professionals must evaluate drug use by the elderly and be aware of the risks of drug misuse by this vulnerable group.

Aged↗

PubMed1994

Sleep problems in the elderly.

Sleep problems in older adults are so common that nearly half of all hypnotic prescriptions written are for persons over 65 years old. Although normal aging affects sleep, the practitioner should evaluate the many factors that cause insomnia: medical illness, psychiatric illness, dementia, alcohol and/or polypharmacy, restless legs syndrome, periodic leg movements, and sleep apnea syndrome. Nonpharmacologic treatment of sleep disorders is preferred. The nurse practitioner can assess and manage elderly patients with sleep disorders, but they need to refer those who can benefit from evaluation to a sleep disorder center.

Aged↗