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PubMed1990

Drug prescribing for schizophrenic out-patients on depot injections. Repeat surveys over 18 years.

Serial surveys of the prescribing practices of psychiatrists for schizophrenic out-patients over 1970-88 showed important changes. During the interval 1970-83, polypharmacy and the use of multiple neuroleptics were reduced. The total dose of neuroleptics prescribed fell and the proportion administered by depot injection increased. Since 1983, however, some of these favourable trends have been reversed. Prescribing practices may also vary between teaching and non-teaching hospitals.

Adolescent↗
PubMed1990

Reduction in antipsychotic drug dosage in mentally handicapped patients. A hospital study.

An investigation in a large mental handicap hospital revealed that 24% of the in-patients were receiving antipsychotic drugs. Chlorpromazine and thioridazine prescriptions accounted for 62% of the total while 10% of patients received depot preparations. Fifty-five per cent of the patients receiving these drugs had no established psychiatric diagnosis; most of these could be categorised as having a behaviour disorder. Patients aged 30-50 received higher doses, and female patients received a significantly higher mean dosage than male ones. In the patients receiving neuroleptic drugs who had also been taking them four years previously, there was a significant reduction in the dosage of the drugs received and the extent of polypharmacy of these agents. A mandatory requirement to review all prescriptions annually, implemented in 1984, may be a reason for this.

Adolescent↗
PubMed2004

Testing for diabetes in hospitalised patients prescribed antipsychotic drugs.

BACKGROUND: Studies using computer databases suggest that atypical antipsychotic agents are more likely to be associated with diabetes than are conventional drugs. AIMS: To discover the extent of testing for diabetes mellitus in hospital in-patients prescribed antipsychotics. METHOD: Prescription charts were screened to identify patients prescribed antipsychotics. Case notes were then searched for evidence of testing for diabetes. RESULTS: In all, 606 patients were prescribed antipsychotics, of whom 250 (41.3%) had evidence of prior testing for diabetes. Patients prescribed atypicals were 40% more likely to have been tested than those prescribed conventional drugs (RR =1.4,95% CI1.1-1.9). Adjusted odds ratios v. conventional antipsychotics for conventional antipsychotics for testing were significantly higher for clozapine (OR=4.64,95% CI 2.42-8.90), olanzapine (OR=1.85,95% CI1.04-3.30) and antipsychotic polypharmacy (OR=2.96,95% CI1.59-5.52). CONCLUSIONS: Testing for diabetes was undertaken in less than half of the patients studied. Testing was more common in those receiving atypical antipsychotics. Apparent differences in claimed causal association of the use of some antipsychotics with diabetes may in part reflect different rates of testing.

Adolescent↗
PubMed2006

Telephone interventions by nursing students: improving outcomes for heart failure patients in the community.

Community care for heart failure patients is difficult due to multiple comorbidities, polypharmacy, and advanced age of patients. Studies show that hospital admissions and emergency room visits decrease with increased nursing interventions in home and community settings. The purpose of this study(1) was to assess the effectiveness of regular telephone interventions by nursing students on outcomes of heart failure patients in the home. Senior students were paired with community nursing staff and assigned 2 heart failure patients to follow up by telephone calls for 12 to 14 weeks. Patients who received telephone interventions had fewer hospital readmissions (13%) than the comparison group (35%). Patients in the telephone intervention group also had fewer overt heart failure symptoms as measured by the Minnesota Living With Heart Failure Questionnaire.

Aftercare↗
PubMed1994

Selegiline in the treatment of narcolepsy.

We treated 17 narcolepsy patients in a placebo-controlled, double-blind, crossover trial with 10-, 20-, 30-, and 40-mg daily doses of selegiline, a monoamine oxidase inhibitor widely used in Parkinson's disease. There was a dose-dependent as well as a statistically and clinically significant improvement in narcoleptic symptoms and polygraphic measures. At 40 mg, there was a 36% reduction in the number of daytime sleep episodes and a 34% reduction in their duration (compared with placebo, mean values). The number of excessive sleepiness episodes decreased by 43%, and the duration decreased by 47%. The number of cataplectic attacks was reduced by 89%. On the multiple sleep latency test, the REM sleep latency increased from 5.0 to 13.3 minutes, and the number of sleep-onset REM periods decreased from 3.1 to 0.6. Sleep (S1) latency was not changed. No intolerable adverse events occurred. The effective dose range was 20 to 40 mg, requiring a low-tyramine diet, which was easy to maintain. In conclusion, selegiline alleviates both main symptoms of narcolepsy--the abnormal sleep tendency and cataplexy. Thus, treatment with selegiline makes it possible to avoid polypharmacy and to use a potent stimulant without known addiction risk.

Adolescent↗
PubMed1997

Risk factors for status epilepticus in children with symptomatic epilepsy.

The purpose of this study was to determine risk factors for status epilepticus (SE) in children with symptomatic epilepsy through a retrospective case-control study. Patients (44 children with a prior diagnosis of symptomatic epilepsy experiencing one or more episodes of SE between January 1, 1991, and June 1, 1995) were matched for age at follow-up to controls (88 children with symptomatic epilepsy without SE during that interval) and medical records were reviewed. Patients and controls did not differ in etiology or in age at epilepsy onset (1 year 5 months [SD, 2 years 3 months] versus 1 year 3 months [SD, 1 year 5 months]). Univariate analysis revealed significant associations between SE and several factors, including history of a first seizure as SE, partial epilepsy, partial seizures with secondary generalization, focal paroxysmal abnormalities and focal background abnormalities on EEG, and generalized abnormalities on neuroimaging. Groups did not differ in the proportion of patients on polypharmacy or with subtherapeutic serum antiepileptic drug levels, but there was a trend for greater use of phenobarbital in patients (57% versus 38%, odds ratio (OR) = 2.6, p = 0.057). With multiple logistic regression, four factors emerged as independent predictors of SE risk: focal background EEG abnormalities (OR = 6.51, p = 0.0005), partial seizures with secondary generalization (OR = 4.61, p = 0.0021), first seizure as SE (OR = 3.99, p = 0.034), and generalized abnormalities on neuroimaging (OR = 2.85, p = 0.034). These four factors are indicators of a higher risk of SE in children with symptomatic epilepsy.

Case-Control Studies↗
PubMed2001

Sudden unexplained death in children with epilepsy.

BACKGROUND: Sudden unexplained death is a significant cause of mortality in people with epilepsy. Risk factors that have been identified include male sex, poor compliance with medications, and antiepileptic drug (AED) polypharmacy. However, these may not apply to the pediatric population in which the causes of epilepsy differ from the adult population. Therefore, risk factors for sudden unexplained death in epilepsy (SUDEP) in children must be evaluated independently from those in the adult population. METHODS: Cases of SUDEP in children less than 18 years of age occurring over a 10-year period in the province of Ontario, Canada, were identified. Records were reviewed for demographic and clinical features and neuropathology findings. RESULTS: Twenty-seven cases of SUDEP in children were identified. Sixty-three percent were male. Age at death ranged from 8 months to 15 years. Fourteen children had symptomatic epilepsy (52%), five had cryptogenic epilepsy (18%), and eight had idiopathic epilepsy (30%). Twelve children were treated with one AED (46%), 10 were on two AED (38%), and three were on three AED (12%). At the time of death, seven children had one serum AED concentration below the therapeutic range (35%) and 12 children had AED levels within the therapeutic range (60%). CONCLUSIONS: This case series represents the largest series of sudden unexplained death in children with epilepsy. At least two previously described risk factors for SUDEP in adults, low serum AED levels at time of death and AED polytherapy, do not appear to be significant in children.

Adolescent↗
PubMed2002

Effect of antiepileptic drugs on bone density in ambulatory patients.

BACKGROUND: Long-term antiepileptic drug (AED) use causes multiple abnormalities in calcium and bone metabolism that have been most extensively described in institutionalized patients. The objective is to determine the effect of AED on vitamin D levels and bone density in ambulatory patients and to compare the effects of enzyme-inducing and -noninducing AED and of single vs multiple therapy on bone density. METHODS: A cross-sectional evaluation was conducted of 71 patients (42 adults and 29 children/adolescents) on anticonvulsant therapy for at least 6 months who presented to neurologists at a tertiary referral center. Bone mineral density (BMD) as well as serum 25 hydroxy-vitamin D (25-OHD) levels were measured. A detailed questionnaire assessing calcium intake as well as previous and current intake of antiepileptic medications was administered to all patients. RESULTS: Over 50% of adults and children/adolescents had low 25-OHD levels, but this finding did not correlate with BMD. Antiepileptic therapy decreased BMD in adults. Generalized seizures, duration of epilepsy, and polypharmacy were significant determinants of BMD, more so at skeletal sites enriched in cortical bone. Subjects on enzyme-inducing drugs such as phenytoin, phenobarbital, carbamazepine, and primidone tended to have lower BMD than those on noninducers such as valproic acid, lamotrigine, clonazepam, gabapentin, topamirate, and ethosuximide. CONCLUSION: Epilepsy and its therapy, including the newer drugs, are risk factors for low bone density, irrespective of vitamin D levels. Skeletal monitoring with the institution of appropriate therapy is indicated in patients on chronic antiepileptic therapy.

Adolescent↗
PubMed1981

Phenytoin: pharmacokinetics and clinical therapeutics.

Phenytoin is a highly effective anticonvulsant medication that is considered to be the treatment of choice for generalized major motor and focal epileptic seizures. An understanding of the pharmacokinetic properties of phenytoin greatly facilitates the management of seizure patients. The judicious use of serum-monitoring techniques coupled with careful clinical evaluations enable one to obtain the optimal anticonvulsant effect, freedom from dose-related toxicity, and the avoidance of unnecessary polypharmacy.

Abnormalities, Drug-Induced↗
PubMedDate not supplied

Health visitor risk assessment for preventing falls in elderly people.

This study was undertaken to look at the feasibility of a health visitor risk assessment for falls at the time of the routine health check for people aged 75 years and above. A total of 162 people were eligible for inclusion in the study. The standard over-75 assessment check was carried out either in the GP surgery or the person's home. A questionnaire was developed to obtain additional information not collected in the routine health check. The results identified two key risk areas: a history of polypharmacy and living in sheltered housing. There were no differences for a range of physical, emotional and environmental factors between people who had fallen and those who had not. A larger study is required to look at the identification of risk factors for falling at the routine over-75 health check, and appropriate referrals that can be put into place to deal with any problems uncovered. Education of health professionals on the risk factors of falls is also required.

Accidental Falls↗
PubMed2003

Atypical and conventional depot medications.

The introduction of atypical antipsychotics created a therapeutic dilemma between choosing the oral novel antipsychotic or the conventional depot form. Clinicians want the advantages of both, resulting in higher levels of polypharmacy. Modern psychiatry is probably in a transitional stage from the depot culture to safer oral medications or even to a safer depot culture.

Administration, Oral↗
PubMed2004

Needs and preference assessment for an in-home nutrition education program using social marketing theory.

Nutrition education programs for elder caregivers (CG) and their elder care recipients (CR) are important in preventing malnutrition. Using Social Marketing Theory, this study assessed the needs and preferences for nutrition education in elder CGs and their CRs in Guilford County, NC. Thirty-two pairs of community-residing elder CGs/CRs and three focus groups (FGs) participated. Health and diet questionnaires were administered to all CGs/CRs during in-home interviews. CGs/CRs and FGs evaluated nutrition education materials. Questionnaires were analyzed using SPSS v9. Ethnograph v5.0 was used to code the interviews regarding the education materials. The CGs were middle age (58.9 years), overweight (BMI = 28.8) Caucasian women. The CRs were old (79.4 years), overweight (BMI = 26.0) Caucasian women. Identified malnutrition risk factors of CGs and CRs included inadequate fluid and dietary intake, polypharmacy, and chronic disease. Identified nutrition needs and education preferences of CGs/CRs were similar. Perceived nutrition education preferences of the FGs did not reflect the interests of the CGs/CRs. This information is being used to revise the education materials and develop an in-home nutrition education program for CGs and CRs in Guilford County, NC.

Aged↗
PubMedDate not supplied

The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence.

OBJECTIVES: To provide an updated review of the literature on the extent of and risk factors for inappropriate prescribing in the elderly. METHODS: A comprehensive review of the most recent publications in English assessing inappropriate prescriptions for elderly patients in the United States using the 1997 version of the Beers explicit criteria. The reviewed articles were obtained via an electronic search of the MEDLINE database for articles published between 1997 and 2001 and a manual search through major journals for articles referenced in those located through MEDLINE. Search terms were Beers, explicit criteria, inappropriate drug use, prescribing, prescriptions, medication use, elderly, and health outcomes. RESULTS: Using the updated explicit criteria, a total of 11 empirical studies were identified, all of which were conducted using observational surveys or claims databases. The reported prevalence of elderly patients using at least one inappropriately prescribed drug ranged from a high of 40% for a population of nursing home patients to 21.3% for community-dwelling patients over age 65. Propoxyphene, amitriptyline, long-acting benzodiazepines (e.g., chlordiazepoxide, diazepam, flurazepam), and dipyridamole are among the most commonly occurring inappropriate prescriptions. With a few exceptions, the most significant patient-related predictors of inappropriate prescribing include polypharmacy, poor health status, and female sex. Other potential risk factors include prescribing location, ethnicity, age, and referral status. Limited evidence was found of increased health care utilization and poorer quality of life resulting from inappropriate drug use in the elderly in Medicare health maintenance organization and emergency department settings. CONCLUSION: The prevalence of inappropriate prescribing remains alarmingly high for the elderly in general and for nursing home residents in particular. This review identified some attributes of the elderly groups most vulnerable to inappropriate prescribing. Future research should document more evidence regarding the adverse impact of inappropriate prescribing on total health care costs and patient health outcomes.

Aged↗
PubMed2000

Recent advances in geriatrics: drug-related problems in the elderly.

OBJECTIVE: To review recent articles examining drug-related problems in the elderly and comment on their potential impact on geriatric pharmacy practice. DATA SOURCES: Six articles published in 1997 and 1998. DATA SYNTHESIS: One study estimated that the cost of drug-related morbidity and mortality with the services of consultant pharmacists was $4 billion, compared with $7.6 billion without the services of consultant pharmacists. A study of ambulatory elderly patients with polypharmacy documented that 35% reported experiencing at least one adverse drug event within the previous year. Another study of ambulatory elderly found that in those with discontinued medications, adverse drug withdrawal events were uncommon. Two studies, one from Canada and one from the US, describe the development, by consensus, of explicit criteria for defining and identifying inappropriate drug use in the elderly (i.e., drugs to avoid, drugs with dose limits, drug-drug and drug-disease interactions). Finally, a modified Delphi survey of an expert panel reached consensus on 18 potential risk factors for drug-related factors in long-term care facility residents. CONCLUSIONS: Drug-related problems are considerable for elderly patients. Data from published studies should provide some guidance for today's practitioners as well as direction regarding future research.

Aged↗
PubMed2003

Measurement, correlates, and health outcomes of medication adherence among seniors.

OBJECTIVE: To provide a comprehensive review of the literature on the measurement, correlates, and health outcomes of medication adherence among community-dwelling older adults. DATA SOURCES: Searches of MEDLINE, PubMed, and International Pharmaceutical Abstracts databases for English-language literature (1966-December 2002) were conducted using one or more of the following terms: elderly, adherence/nonadherence, compliance/noncompliance, medication/drug, methodology/measurement, and hospitalization. STUDY SELECTION AND DATA EXTRACTION: From the above search, studies of medication adherence in community-dwelling seniors were selected for review along with relevant publications from the reference lists of articles identified in the initial database search. DATA SYNTHESIS: Although several methods are available for the assessment of adherence, accurate measurement continues to be difficult. The available evidence suggests that polypharmacy and poor patient-healthcare provider relationships (including the use of multiple providers) may be major determinants of nonadherence among older persons, with the impact of most sociodemographic factors being negligible. There is little consensus regarding other determinants of nonadherence. Relatively few high-quality investigations have examined the associations between nonadherence and subsequent health outcomes. Available data provide some support for increased health risks with nonadherence. However, interventions to improve adherence have seldom demonstrated positive effects on health outcomes. CONCLUSIONS: There are few empirical data to support a simple systematic descriptor of the nonadherent patient. The inconsistencies across studies may be attributable, in part, to the inherent difficulties involved in the measurement of a behavioral risk factor such as nonadherence. Future research in this area would be strengthened by incorporation of detailed assessments of patient-reported reasons for nonadherence, the appropriateness of drug regimens, and the effect of nonadherence on health outcomes.

Activities of Daily Living↗
PubMed2004

Inappropriate medication use among frail elderly inpatients.

BACKGROUND: Inappropriate prescribing in frail elderly inpatients has not received as much investigation as in frail elderly nursing home patients. OBJECTIVE: To determine the prevalence and predictors of inappropriate prescribing for hospitalized frail elderly patients. METHODS: The study was conducted at 11 Veterans Affairs Medical Centers and involved a sample of 397 frail elderly inpatients. Inappropriate prescribing was measured by physician-pharmacist pair's consensus ratings for 10 criteria on the Medication Appropriateness Index (MAI). The MAI ratings generated a weighted score of 0-18 per medication (higher score = more inappropriate) and were summed across medications to achieve a patient score. RESULTS: Overall, 365 (91.9%) patients had > or =1 medications with > or =1 MAI criteria rated as inappropriate. The most common problems involved expensive drugs (70.0%), impractical directions (55.2%), and incorrect dosages (50.9%). The most common drug classes with appropriateness problems were gastric (50.6%), cardiovascular (47.6%), and central nervous system (23.9%). The mean +/- SD MAI score per person was 8.9 +/- 7.6. Stepwise ordinal logistic regression analyses revealed that both the number of prescription (adjusted OR 1.28; 95% CI 1.21 to 1.36) and nonprescription drugs (adjusted OR 1.17; 95% CI 1.06 to 1.29) were related to higher MAI scores. Analyses excluding the number of drugs revealed that the Charlson index (adjusted OR 1.62; 95% CI 1.12 to 2.35) and fair/poor self-rated health (adjusted OR 1.15; 95% CI 1.05 to 1.26) were related to higher MAI scores. CONCLUSIONS: Inappropriate drug prescribing is common for frail elderly veteran inpatients and is related to polypharmacy and specific health status characteristics.

Aged↗
PubMed2005

Herbal use among US elderly: 2002 National Health Interview Survey.

BACKGROUND: Use of herbal products among the elderly is an important concern for healthcare professionals. The presence of polypharmacy and multiple comorbidities places the elderly at high risk for herb-drug and herb-disease interactions. Limited data exist regarding herbal use among the US elderly population. OBJECTIVE: To evaluate the incidence of and attitudes toward herbal use in a nationally representative sample of US elderly patients >/=65 years of age. METHODS: We performed a descriptive analysis of public domain data collected in the 2002 National Health Interview Survey. Statistical analyses were conducted through use of SUDAAN software with Taylor series linearization for variance estimation. RESULTS: Analysis of weighted data revealed that 12.9% +/- 0.5% (mean +/- SE) of US elderly people had used an herbal supplement within the past 12 months. Use was greatest among individuals 65-69 years of age, females, Hispanic and non-Hispanic ethnic minorities, and respondents with a greater income, higher education level, or more positive self-reported health status. Among elderly people purchasing over-the-counter and prescription drugs, herbal use was 13.9% +/- 0.6% and 12.8% +/- 0.6%, respectively. Glucosamine, echinacea, and garlic supplements represented the most common herbals used. Benefit from combined herbal and conventional therapy was the most common reason cited for use; however, 50.9% +/- 2.2% of users did not discuss herbal therapy with a medical professional. Several theoretical herb-disease interactions were identified. CONCLUSIONS: The use of herbal products among the US elderly has risen over the past 5 years, whereas discussion of such use with medical professionals remains suboptimal.

Aged↗