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PubMed1998

An accelerometry-based system for the assessment of balance and postural sway.

The aim of this investigation was to develop an inexpensive, efficient system for the clinical assessment of static and dynamic balance and postural sway using accelerometry-based measurements. Subjects consisted of 10 young (range 18-32 years) and 10 older (range 69-86 years) individuals screened for polypharmacy and history of cardiovascular, neurological or orthopedic health conditions. A lightweight uniaxial accelerometer and general-purpose microcomputer were used to obtain measurements of postural sway. Customized software was written to acquire the data and provide a real-time display consisting of amplitude and frequency characteristics of the sway profile. Intraclass reliability coefficients greater than R = 0.75 were obtained in both eyes-open and challenging-standing balance tasks. Preliminary results demonstrate that the instrumentation can be used to discriminate among balance tasks and to differentiate healthy older adults from those with a tendency toward frequent falls. Moreover, the technique described yields a simple-to-administer, inexpensive procedure that can be conducted in the home or another natural environment. Accelerometry also allows for balance training and re-learning, using tasks that might ordinarily pose a balance challenge for the older or frail adult.

Adolescent↗

PubMed1999

Improving outcomes in congestive heart failure: Val-HeFT. Valsartan in Heart Failure Trial.

The aims of the treatment of heart failure are to improve the quality of life and slow the progression of cardiac disease. Improvement of quality of life is best assessed by questionnaire; progression of the disease is assessed by measuring mortality and morbidity. The agenda for the future is to establish intermediate markers for progression of cardiac disease that can be substituted for morbidity and mortality, and thus improve the efficiency and shorten the follow-up of clinical trials. At present, polypharmacy is required to achieve optimal improvements in quality and duration of life. Furthermore, some drugs may favorably affect one end point and adversely affect the other; for example, beta-blockers may exert adverse short-term effects on quality of life but may slow progression of the disease. Certain inotropic drugs may reduce symptoms but shorten life expectancy. Angiotensin-converting enzyme (ACE) inhibitors have exerted favorable effects on both quality of life and mortality, but the magnitude of these benefits has been disappointingly small. Persistent angiotensin-induced vasoconstriction and endocrine effects, despite ACE inhibition, is one possible explanation. The Valsartan in Heart Failure Trial (Val-HeFT) has been designed to test the efficacy and safety of the AT(1) receptor blocker (ARB) valsartan in combination with ACE inhibitors and all other prescribed therapies in patients with heart failure. The study is powered to detect a mortality benefit and should therefore establish the role of ARBs in this patient group. When this trial and other ongoing studies are completed, we will be more able to define the role of ARBs in the treatment of heart failure.

Angiotensin II↗

PubMed2003

Primary and secondary stroke prevention in nonrheumatic atrial fibrillation by oral anticoagulation.

The risk of stroke or embolism in atrial fibrillation (AF) patients can be reduced by 68% by oral anticoagulation (OAC). This review is aimed to (1) summarize indications for OAC in patients with AF, (2) give an overview of the current knowledge of risk factors for bleeding complications of OAC and (3) give practical recommendations for an optimal OAC therapy in the neurological setting. Indications for OAC are increased age (>75 years), arterial hypertension, diabetes mellitus, previous thromboembolism, heart failure and, probably, coronary heart disease. Risk factors for bleeding complications are overanticoagulation with international normalized ratios (INRs) >3.0, increased age, arterial hypertension, diabetes mellitus, previous thromboembolism, polypharmacy, the early phase of OAC therapy and a lack of patients' education. Before initiation of OAC, the patient should be screened for potential bleeding sites. Careful monitoring of OAC comprises fixed appointments for the INR value determination, tracking for the patient, if he does not attend, advices about pain therapy, information about the influence of diet on the INR value and drug interaction, unscheduled INR determination in case of acute disorders and regular assessment if OAC is still indicated. Monitoring of OAC needs an effort, which has to be adequately estimated by the health care system.

Administration, Oral↗

PubMed2006

Pharmacokinetics of fluoxetine in elderly men and women.

Fluoxetine is widely prescribed as an antidepressant for geriatric patients. Despite a large scientific literature describing its efficacy and safety, there are few published data describing the pharmacokinetics of fluoxetine in the elderly. Given the common practice of polypharmacy in this population, additional pharmacokinetic information in elderly men and women is needed so that physicians can better assess potential drug-drug interactions. Twenty-five subjects, men and women between ages 65 and 83, received 20 mg of fluoxetine for 1 week followed by 40 mg for 5 weeks. Serum fluoxetine levels were measured during the period of drug administration and for 8 weeks after. The plasma concentration of fluoxetine and norfluoxetine in our subjects was higher than previously reported in the literature. Elderly women had a significantly higher serum level of norfluoxetine than men. The terminal half-life of norfluoxetine was longer in patients over age 75; elderly women had a significantly slower rate of norfluoxetine elimination than similarly aged men.

Age Factors↗

PubMed2006

Underappreciated predictors for postdischarge mortality in acute hospitalized oldest-old patients.

BACKGROUND: Although oldest-old, those aged 85 years and older, patients are the fastest growing segment, clinical evidences regarding the acute care of oldest-old patients are still lacking. Because acute medical conditions requiring emergent hospitalization is frequently followed by high rate of progressive physical decline and increased mortality after discharge in oldest-old patients, prognostic information collected during hospitalization can provide the basis for discussion about the goals of care and therapy. The aim of our study was to identify predictive factors for postdischarge mortality in oldest-old patients. METHODS: The study included 403 oldest-old patients discharged from the acute care setting of a general hospital, who were followed-up for 1 year. Predictive values of the patients' characteristics collected during their hospitalization for 1-year mortality were identified utilizing Cox proportional hazard regression analysis. RESULTS: During 1-year follow-up, 104 patients (25.8%) died. The variables independently associated with 1-year mortality in multivariate analysis were the Charlson Comorbidity Index equal or greater than 2 [HR (hazard ratio) 4.71, 95%CI (confidence interval) 1.09-20.42], six or more prescribed medications at discharge (HR 3.12, 95% CI 1.39-6.99), benzodiazepines use (HR 1.64, 95% CI 1.04-2.60), nonsteroidal anti-inflammatory drugs use (HR 1.70, 95% CI 1.10-2.63), albumin less than or equaling 3.4 g/dl (HR 2.16, 95% CI 1.13-4.14), hemoglobin 10-12 g/dl (HR 2.32, 95% CI 1.22-3.56), hemoglobin less than 10 g/dl (HR 2.67, 95% CI 1.43-4.95), the presence of pressure sores (HR 1.84, 95% CI 1.14-2.97), and a history of delirium (HR 2.24, 95% CI 1.32-3.79). Functional impairment assessed by the Katz Index was only weakly associated with mortality (HR 1.24, 95% CI 0.53-2.91). CONCLUSION: Although often underappreciated, polypharmacy, particular medication use, anemia, the presence of pressure sores, and a history of delirium were important predictors for postdischarge mortality in oldest-old patients.

Aged, 80 and over↗

PubMed1985

Pharmacotherapy of chronic hospitalized schizophrenics: prescription practices.

Prescription practices were examined as part of a multinational study of chronic hospitalized schizophrenic patients. The study included a total of 768 patients from 8 countries. All patients had a diagnosis (ICD-9) of schizophrenia and met defined criteria for chronic hospitalization. The patients were treated with psychotropic drugs from 6 categories, i.e., neuroleptics, antidepressants, lithium salts, anxiolytics, anticonvulsants, and antiparkinsonian medications, as well as with a variety of nonpsychotropic drugs. The majority of the patients received concurrently more than 1 neuroleptic, medications from 2 or more categories, and neuroleptics combined with other agents. Polypharmacy appeared to be universal in this population.

Adult↗

PubMed2005

Evolution of cognitive impairment after stroke and risk factors for delayed progression.

BACKGROUND AND PURPOSE: Cognitive decline occurs in approximately 30% of stroke patients. Acute risk factors have been identified, but long-term risk has not been examined in large samples. The purpose of this research was to determine factors associated with the progression of cognitive impairment after stroke. METHODS: Consecutive stroke patients (193) without previous dementia were assessed 3 months after stroke with an extensive neuropsychological battery and diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition criteria and the Clinical Dementia Rating as normal (139), cognitive decline without dementia (18), or dementia (18 mild, 10 moderate, and 8 severe). After a 24-month follow-up, they were classified as stable, progressing, or improving, according to change in Clinical Dementia Rating score. The determinants of progression of cognitive decline were ascertained by logistic regression analysis of all clinical, neuroimaging, and complementary data. RESULTS: Cognitive status at 24 months was stable in most cases (151; 78.2%), decline progressed in 27 (14%; 6 demented and 21 nondemented), and improved in 15 (7.8%; 7 demented and 8 nondemented). Seven nondemented patients became demented at 24 months, and 5 demented became nondemented. The age (odds ratio [OR], 1.05; 95% CI, 1.01 to 1.1), mental decline before stroke (OR, 1.14; 95% CI, 1.02 to 1.27), number of prescribed drugs (OR, 1.34; 95% CI, 1.05 to 1.72), diastolic blood pressure on admission (OR, 0.96; 95% CI, 0.93 to 0.99), and episodes of hypotension during admission (OR, 7.61; 95% CI, 1.11 to 52.1) were significantly associated with cognitive deterioration. CONCLUSIONS: Cognition is rather stable for 2 years after stroke. Both progression and improvement of cognitive impairment are frequent in demented patients. Age, previous cognitive decline, polypharmacy, and hypotension during admission are risk factors for progression.

Aged↗

PubMed1976

Peer review of prescribing patterns in a CMHC.

Monitoring the prescribing patterns of psychiatrists is a challenging and now necessary professional responsibility. The authors describe a peer review and feedback system in a decentralized CMHC, linked to continuing education in psychopharmacology, that made staff psychiatrists familiar with the state of the art and accountable for practice within its guidelines. Data are presented that confirm shifts from polypharmacy toward more appropriate use of psychotropic medications.

Community Mental Health Services↗

PubMed1984

Clinician-computer interaction: automated review of psychotropic drugs.

Five years after its introduction at a state mental hospital, an automated drug exception review system continues to show a long-term impact on the prescribing practices of hospital physicians. Although the overall rate of exceptions has remained low, approximately 25% of all new exceptions pointed out by the computer result in a change in the order by the physician. The fact that 60% of new exceptions are justified suggests that some forms of polypharmacy may be appropriate. The integration of the exception-reporting system into the clinical review process has avoided the danger of the computer's being seen as an adversary to the clinician or as exerting undue control over psychopharmacologic prescription practices.

Attitude of Health Personnel↗

PubMed1997

Economic reforms and the acute inpatient care of patients with schizophrenia: the Chinese experience.

OBJECTIVE: This study compared insured and uninsured schizophrenic inpatients in China and examined changes in the acute inpatient care of schizophrenic patients during China's economic reform era. METHOD: Detailed chart reviews of 50 randomly selected inpatients discharged from a hospital in central China each year from 1984 through 1993 identified 321 patients with schizophrenia. Demographic, insurance, treatment, and cost data of these patients were collected from the charts. RESULTS: With logistic regression models to control for confounding variables, the analyses showed that the 129 insured patients were significantly more likely than the 192 uninsured patients to be urban residents, to be older, to have had 7 or more years of schooling, and to have had more psychiatric hospitalizations; moreover, their index admissions were longer and were more likely to include use of traditional Chinese medications. The estimated 19% of schizophrenic individuals in the community with health insurance receive inpatient treatment 2.8 times more frequently than the 81% without insurance. Compared to admissions in 1984-1988, admissions in 1989-1993 were significantly shorter and involved longer periods of polypharmacy with multiple antipsychotic medications but included lower mean chlorpromazine-equivalent doses of medication. The relative cost of inpatient care for an acute episode of schizophrenia increased 3.5-fold over the 10-year period, from 11% of mean annual household income in 1984 to 37% in 1993. CONCLUSIONS: Changes in the incentive system for care providers and rapid increases in the cost of care during the economic reform era have resulted in increasingly restricted availability of services for the many schizophrenic patients without health insurance.

Adult↗

PubMed1998

Mood stabilizer combinations: a review of safety and efficacy.

OBJECTIVE: Polypharmacy is common in the treatment of refractory bipolar disorder. The purpose of this article is to review the safety and efficacy of mood stabilizers in combinations. METHOD: A manual and computer (MEDLINE) search was performed for combinations of the most commonly used mood-stabilizing agents. RESULTS: The authors review safety and efficacy data on the more frequently encountered combinations of established and putative mood stabilizers. CONCLUSIONS: There have been few controlled studies of the use of combinations of mood stabilizers. The interactions of such combinations are sometimes complex, often very useful, and potentially dangerous. One general rule that may reduce the risks of toxic drug interactions is to add medication to the patient's current regimen in modest doses and increase the dose slowly. The safest and most efficacious mood stabilizer combinations appear to be the mixtures of anticonvulsants and lithium, particularly valproate plus lithium. Once the mechanisms of the mood stabilizers are identified, it is possible that a more rational approach to combination therapy will emerge, based on synergism at the sites of action.

Acetates↗

PubMed2003

Combination antipsychotic therapy in clinical practice.

OBJECTIVE: Surveys have shown that antipsychotic drug combinations are frequently prescribed, yet few clinical studies have examined this practice. Experts have generally recommended antipsychotic combinations, especially those combining an atypical and a conventional antipsychotic, as a measure of last resort. A survey of prescribers was conducted to examine why combination antipsychotic therapy is being used in outpatient clinical practice. METHODS: Antipsychotic prescribing practices in the Department of Veterans Affairs Puget Sound Health System were reviewed for a six-month period during 1998-1999. Data on the use of atypical and conventional antipsychotics in combination were collected. RESULTS: A total of 1,794 patients received prescriptions for at least one antipsychotic medication during the study period, of which 715 (40 percent) received an atypical agent. Ninety-three patients (13 percent) who were treated with an atypical antipsychotic received a prescription for combination antipsychotic therapy for at least 30 days. In cases in which both a conventional and an atypical agent were prescribed, the primary reason given for adding a conventional antipsychotic medication was to treat persistent positive symptoms. The primary reason an atypical agent was added to a conventional agent was to switch medications to the atypical agent; however, a significant number of patients became "stuck" on the combination. CONCLUSIONS: The results of this study support previous reports of the frequent use of combination antipsychotic therapy in clinical practice. Prospective controlled trials are needed to substantiate perceptions that combination antipsychotic therapy is clinically beneficial and to provide guidelines on when and for whom antipsychotic polypharmacy should be considered.

Adult↗

PubMed2005

Patterns and quality of treatment for patients with schizophrenia in routine psychiatric practice.

OBJECTIVES: This study provided generalizable national data on the treatment of adult patients with schizophrenia in the United States and assessed conformance with the practice guideline treatment recommendations of the Schizophrenia Patient Outcomes Research Team and the American Psychiatric Association. METHODS: National data from the American Psychiatric Institute for Research and Education's 1999 Practice Research Network study of psychiatric patients and treatments were used to examine treatment patterns for 151 adult patients with schizophrenia. Analyses were performed and adjusted for the weights and sample design to generate nationally representative estimates. RESULTS: Findings indicated that patients with schizophrenia who were treated by psychiatrists had complex clinical problems and were markedly disabled. Forty-one percent of patients had a comorbid axis I disorder, and 75 percent were currently unemployed. Thirty-five percent were currently experiencing medication side effects, and 37 percent were currently experiencing problems with treatment adherence. Although most patients received guideline-consistent psychopharmacologic treatment, treatment was characterized by significant polypharmacy. Rates of conformance with the guideline recommendations were significantly lower for psychosocial recommendations than for psychopharmacologic recommendations. Although 69 percent of patients received at least some psychosocial treatment, none of the unemployed patients received vocational rehabilitation services in the past 30 days. CONCLUSIONS: These data suggest unmet need for psychosocial treatment services among individuals with schizophrenia. These findings raise questions about whether currently available antipsychotic medications are being used optimally or whether they offer limited effectiveness for patients with complex clinical problems who are treated in routine psychiatric practice.

Adolescent↗

PubMed2005

Clozapine reduces violent behavior in heterogeneous diagnostic groups.

Violent behavior is a significant problem in the psychiatric hospital setting. Persistently violent patients often require seclusion and/or restraints and typically receive high doses of medication and polypharmacy. Clozapine has been found to be effective in reducing aggression in patients with psychosis. Thus, we examined the effects of clozapine in a heterogeneous group of persistently violent patients. A chart review of the effect of clozapine in persistently violent patients was performed. Changes in the number of violent episodes and the need for seclusion and restraint were assessed for a 3-month period before and after receiving clozapine. In this group of five, carefully selected, persistently violent patients, clozapine treatment resulted in marked decreases in violent episodes and the use of seclusion and restraint. These data suggest a role for clozapine in the treatment of persistently violent patients irrespective of DSM-IV diagnosis.

Adolescent↗

PubMed2006

Racial differences in medication switching and concomitant prescriptions in the treatment of bipolar disorder.

OBJECTIVE: This study examined whether the practices of switching between classes of medications and prescription of concomitant medications differed between black and non-black patients with bipolar disorders. METHODS: In a retrospective cohort design, data from 1998 to 2004 for patients with diagnoses of bipolar disorders were obtained from a large claims database. Information was obtained on the number of prescriptions for four classes of medications (anticonvulsants, mood stabilizers, and first- and second-generation antipsychotics) as well as on medication switching (between drug classes), concomitant prescriptions, resource use, and outcomes (an emergency department visit or a hospitalization). Logistic models assessed the relationship between outcomes and switching or concomitant prescriptions. RESULTS: The study population consisted of 1,113 adults who received at least one prescription from the four drug classes. Medication switching or concomitant prescriptions were documented for more than one-third of patients (36.6 percent). A significantly greater proportion of black patients received two or more medications from different drug classes (41.1 compared with 34.7 percent). The number of prescriptions was lower for black patients than for non-black patients. Patients for whom switching or concomitant prescriptions were documented were significantly more likely to have an emergency department visit or a hospitalization, and race was a significant predictor of these outcomes. CONCLUSIONS: The prevalence of polypharmacy-medication switching and concomitant prescriptions-was high among patients with bipolar disorder, with a higher prevalence among black patients. Patients who experienced switching or concomitant prescriptions were more likely to visit the emergency department or to be hospitalized.

Adult↗

PubMed2006

Baseline use of concomitant psychotropic medications to treat schizophrenia in the CATIE trial.

OBJECTIVE: This study examined the prevalence and correlates of concomitant psychotropic medications and use of anticholinergic drugs to treat schizophrenia. METHODS: Concomitant medication use was studied at baseline for participants in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) trial. RESULTS: Of the 1,380 patients with baseline medication data, 82 percent were taking psychotropic medications. Of this group, 6 percent were taking two antipsychotics (one first generation and one second generation); 38 percent, antidepressants; 22 percent, anxiolytics; 4 percent, lithium, and 15 percent, other mood stabilizers. The strongest predictors of taking several medications were having anxiety or depression, being female, and taking second-generation antipsychotics. Conversely, African Americans and those with better neurocognitive functioning were less likely to be taking several concomitant psychotropic medications. In some cases symptoms that were likely targets of polypharmacy, such as depression, remained prominent, suggesting only partial response. CONCLUSIONS: Concomitant use of psychotropic medications to treat people with schizophrenia is common. Empirical data demonstrating the effectiveness of many of these agents for this population are lacking.

Adult↗

PubMed1979

A single-bedtime-dose self-medication system.

A medication system in use at the Florida Mental Health Institute is based on the unit-dose procedure and weekly reviews of patients' medications. The program is aimed at reducing the use of polypharmacy and of concentrates and stabilizing patients on a single daily bedtime dose of medication. Once patients are stabilized on a single dose, they are trained by the nurses and through a drug group to manage their medications independently after discharge. The system has produced savings of up to 90 per cent of medication costs per patient and is gaining acceptance in other mental health facilities in the state. The authors believe it has the potential for even greater therapeutic and financial benefits by reducing the recidivism that occurs when discharged patients discontinue their drugs.

Adult↗

PubMed1979

Measuring prescribing practices in a state mental hospital system.

To determine the degree to which Nebraska's three state mental hospitals complied with recognized guidelines for prescription of psychotropic medications, a study was made for 1326 drug orders issued over a five-year period. The prescribing practices in the hospital were then reviewed in relation to the guidelines in areas of polypharmacy, daily dose frequency, time of day, use of p.r.n. orders, drug form, dosages for children and the elderly, dosages during acute and stabilized stages of illness, and brand versus generic names. The study highlighted areas of progress in drug use practices and identified areas for improvement.

Age Factors↗