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PubMed1981

Propoxyphene in postmortem toxicology 1976-1978.

A total of 1859 cases provides the basis for this study in which propoxyphene, and often its major metabolite, was demonstrated by toxicological analysis in the blood or tissues of the deceased at 27 medical examiner or coroner's offices across the United States and Canada. The study period includes the last five months of 1975 through December 1978. The cases describe a clearly defined adult population with a marked tendency toward hypochondria, chronic minor illness, and severe psychiatric problems. The high proportion of suicides (44.1% of the total cases and 54.0% of the drug-caused deaths) and multiple-drug toxicities (88.6%) suggests that the involvement of propoxyphene in many of these fatalities may be of less significance than the phenomenon of "polypharmacy" and self-medication without appropriate medical supervision. This evaluation of propoxyphene provides no evidence that propoxyphene is responsible for "street-drug" fatalities. Its appearance in postmortem toxicological examinations has been declining sharply since 1977, but it continues to be dangerous when used excessively, particularly in combination with alcohol and other central nervous system depressant drugs.

Adolescent↗

PubMed1981

Repeat prescription card--'pink' card.

A prescription card which will prevent duplication of drugs, thus helping to control both polypharmacy and iatrogenic disease, is described. Has the time come to compel all members of the public to carry such a card for presentation every time a patient sees a doctor or pharmacist? Such a scheme could have great merit.

Drug Prescriptions↗

PubMed1995

International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: III. Clinical features affecting experts' therapeutic recommendations in anxiety disorders.

Our objective was to assemble expert clinical experience and judgment in the treatment of anxiety and related disorders in a systematic, quantitative manner. This article reports on some clinical features apart from diagnosis that may affect choice of strategy in the pharmacotherapy of anxiety disorders. A panel of internationally recognized experts in treating anxiety and depression was constituted by multistage peer nomination. Ninety percent (66 of 73) completed an extensive questionnaire. This report focuses on the expert panel's responses to questions on therapeutic options, based on multi-part case vignettes of several anxiety disorders presenting clinical variations within the same diagnosis. In the presence of higher levels of functional impairment, the experts more often recommended formal psychosocial procedures for adjustment disorder; medication for agoraphobia, social phobia, obsessive-compulsive disorder, and adjustment disorder; and polypharmacy for agoraphobia. Their therapeutic recommendations were not materially affected by chronicity in the case of panic disorder. Under the condition of heavy use of alcohol in the case of generalized anxiety disorder, the experts avoided benzodiazepines in favor of various other medications. In the presence of a serious cardiac conduction defect in the case of obsessive-compulsive disorder, they less often recommended medication. Those who did recommend medication changed their preference from tricyclic antidepressants (clomipramine) to selective serotonin reuptake inhibitors. Under the condition of a more severe precipitating event in the case of adjustment disorder, the experts were more likely to recommend both formal psychosocial intervention and medication.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1995

[Drugs as a cause of death. A prospective quality assurance project in a department of medicine].

This study is part of a prospective quality assurance project in a Norwegian county hospital. The major aims of the study were to estimate the number of drug-related deaths; assess whether these were recognized by the clinicians, and (if not) discuss why the clinicians had difficulties in recognizing drug-related deaths. A panel of two internists, one pathologist, one pharmacologist and one pharmacist evaluated all inpatients deaths over a six-month period. Among 3,082 hospitalized patients, 169 died. Of these deaths, 20 were classified as probably (nine) or possibility (11) drug-related. Only two of the deaths were recognized as such by the clinicians in the ward. The reasons for the clinicians failure to recognize adverse drug reactions include frequent presence of multiple diseases, polypharmacy and inadequate guidelines on how to look for adverse reactions to drugs. A two-year survey aimed at studying these aspects in depth is in progress.

Adrenergic beta-Agonists↗

PubMed1994

Special considerations in the use of NSAIDs in the elderly.

As the number of elderly patients with rheumatic conditions continues to increase, rheumatologists are faced with the challenge of providing more effective but safer therapy to their geriatric patients. In 1991, nonsteroidal anti-inflammatory drugs (NSAIDs) accounted for more than 29 million prescriptions worldwide. The elderly are at increased risk for NSAID-associated toxicity, particularly gastrointestinal side effects. Predisposing factors include age-related physiologic changes, underlying conditions, and polypharmacy. Clinical experience shows etodolac, 300 mg twice daily, given to elderly patients with osteoarthritis for 4 weeks, to be effective and well tolerated in this population. Additionally, etodolac may favourably affect mood and cognitive function. With judicious individualisation of therapy and careful monitoring, NSAID therapy can provide a favourable risk-benefit ratio in elderly patients.

Aged↗

PubMed1995

Hypertension induced by drugs and other substances.

The purpose of this article is to review and summarize the literature regarding the effects of medications and other substances on blood pressure. Many substances are known to cause or exacerbate hypertension, including sodium chloride, substances of abuse, nonprescription sympathomimetics, nonsteroidal anti-inflammatory drugs, sex steroids, immunosuppressive therapies, erythopoietin, antidepressants, ergot alkaloids, anesthetic agents, and other substances. With the population aging, the increasing incidence of polypharmacy, and the growth of over-the-counter pharmacological agents, including those which were previously available only by prescription, drug-induced hypertension is assuming heightened importance. Furthermore, these agents represent an important modifiable cause of secondary hypertension, and it is imperative that clinicians recognize this causal relationship.

Adrenergic Agents↗

PubMed1995

Impact of continued geriatric outpatient management on health outcomes of older veterans.

BACKGROUND: Although previous trials have proved inpatient-based geriatric assessment to be beneficial, to our knowledge, the effectiveness of outpatient geriatric assessment has not been established. We examined the effectiveness of an outpatient geriatric evaluation and management (GEM) clinic. METHODS: Hospitalized veterans aged 65 years or older with impairment of activities of daily living, chronic disease, polypharmacy, or two or more hospitalizations in the previous year were randomized to an outpatient GEM team clinic (n = 60) or usual care (n = 68). After an initial comprehensive assessment, they received long-term management in the geriatric clinic. Principal outcomes included health status (mortality, hospitalizations, health perception, and medications), function (activities of daily living, instrumental ADL, and social activity), affect (Center for Epidemiologic Studies-Depression test score and life satisfaction), and cognition (Mini-Mental State examination score). RESULTS: At randomization, no significant differences were noted between the groups. The average age of the patients was 71 years (range, 65 to 93 years). At 1 year following randomization, GEM clinic patients compared with subjects receiving usual care had significantly improved health perception, took fewer medications despite increased number of diagnoses, reported greater social activity, had improved Center for Epidemiologic Studies-Depression scale scores, and had higher life satisfaction scores. There was a trend toward improved performance of activities of daily living for GEM clinic patients. The GEM clinic patients had a 54% lower mortality (6.8% vs 14.9%). Overall, no differences were observed in the total number of hospitalizations between the groups. CONCLUSIONS: The combination of long-term management following comprehensive outpatient assessment significantly improved aspects of health status (including health perception and medications), function (including social activity), and affect (including depression and life satisfaction) for older veterans and may influence mortality and function.

Activities of Daily Living↗

PubMed1995

Antiepileptic drug therapy in the United States: a review of clinical studies and unmet needs.

The goal of epilepsy treatment is complete seizure control with minimal adverse drug reactions. Because no drug is entirely free of adverse effects, the clinician must aim for a balance between efficacy and tolerability. In approximately 40% of patients, however, monotherapy with conventional antiepileptic drugs either is not tolerated or does not provide optimal seizure control. Polypharmacy may be necessary in as many as 30% of patients. As clinicians look to new agents that may produce an overall improved quality of life, they must continue to balance efficacy and adverse effects in evaluating the usefulness of the new vs the established drugs.

Anticonvulsants↗

PubMed1995

The treatment of epilepsy: an overview of clinical practices.

About 30% of patients with epilepsy remain refractory to medical management despite optimal use of conventional antiepileptic drugs. Seizure control for many patients is often achieved at the expense of adverse drug effects. The need for new drugs is obvious. After 15 years, three new antiepileptic drugs are now clinically available: felbamate, gabapentin, and lamotrigine. These drugs have undergone double-blind, controlled clinical trials for efficacy and safety in patients with predominantly simple, complex partial, and generalized tonic-clonic seizures. All of these new drugs will be used initially in a polypharmacy regimen.

Anticonvulsants↗

PubMed1993

Adjunctive medication in the maintenance treatment of schizophrenia and its conceptual implications.

Beyond the continuing use of neuroleptic medication, psychopharmacological treatment approaches during the maintenance phase of schizophrenia often involve adjunctive medication. Appropriate use of such 'polypharmacy' can be crucial to patients in achieving their optimal levels of symptom management and functional capacity, although the risks of side-effects and medication interactions must be weighed. This paper reviews the use of adjunctive anti-Parkinsonian medication, benzodiazepines, propranolol, antidepressants, lithium, and carbamazepine in this context. It also explores a strategy of identifying secondary syndromes in the longitudinal course of schizophrenia which can be approached psychopharmacologically.

Antipsychotic Agents↗

PubMedDate not supplied

Auditory middle latency responses in patients with epilepsy.

Middle latency auditory responses (MLRs) were studied in 55 normal subjects and 49 epileptic patients. We evaluated the function of the auditory system and of the temporal lobe in epileptic patients using MLRs. (1) The patients with epilepsy had significantly prolonged Pa and Nb latencies and the significantly increased amplitude of Pa-Nb component. (2) The prolongation and the increase of MLR components in latency and amplitude were more obvious in patients with intractable epilepsy than patients without intractable epilepsy. (3) The difference between left and right sides was larger in epileptic patients than normal subjects. (4) Epileptic patients with polypharmacy had reduced amplitude of Pa-Nb component and prolonged latency of Pa component than patients with monotherapy. Antiepileptic drugs (AEDs) appeared to decrease the amplitude of Pa-Nb component. It was supposed that the enhancement of amplitude of Pa-Nb component represented the abnormality of central nerve system in epileptic patients, in part.

Adolescent↗

PubMed1993

[Prescribing practice of psychotropic drugs in a psychiatric university clinic].

An investigation on the use of psychotropic drugs in a Swiss university psychiatric hospital shows that compared with other drug surveys drugs were prescribed to relatively fewer patients and polypharmacy was used in less than 50% of the patients. The most frequently administered drugs were neuroleptics, among which, surprisingly. Clozapine ranked first. Antidepressants were prescribed in relatively low doses. A drug survey like ours can provide a basis for the critical discussion of prescribing habits.

Adolescent↗

PubMed1994

[Geriatric dentistry: medical problems as well as disease- and therapy-induced oral disorders].

As in pediatric dentistry, management of the oral problems in elderly patients does not depend on the development of new technical skills, but rather on the knowledge of: biological, psychological and social aspects of primary (physiological or age-related) and secondary (pathological or disease-related) aging; atypical presentations of disease; multiple pathological conditions (polymorbidity, polypathophysiology, polypharmacy); an underreporting of disease; the importance of functional status; the role of an interdisciplinary team; Geriatric medicine refers to social, psychological and clinical aspects of disease in older adults. Geriatric dentistry deals with the respective aspects concerning oral diseases. Chronic conditions as well as their treatment (e.g. medication) are more common with advancing age. They may have major implications for dental practice, leading to changes in oral health behavior and attitudes of the elderly patient with sometimes detrimental effects on oral health. Therefore, different concepts in prevention, diagnosis and therapy of oral diseases are required for the oral care of older adults. Two important consequences must be considered: Firstly, the medical education of the dentist and the dental team must be improved. The dental team must become a member of the group of health-care professionals caring for an aging population (geriatric medicine) to meet the heterogeneous needs of as much as 75% of our future patients. Secondly, there is great need for education of all health-care professionals dealing with elderly patients about possible negative impacts medicine can have on oral health. Identification and diagnosis of oral disease as well as preventive measures must be stressed.

Aged↗

PubMed1994

Hyperthermia and hypothermia in the elderly.

Elderly populations are prone to both hyperthermia and hypothermia because of innate physiologic changes associated with aging, the presence of chronic disease, and the use of polypharmacy. Hyperthermia is a true medical emergency with a high mortality rate, requiring rapid cooling and aggressive supportive care. Hypothermia is a common finding in elderly persons. Patients should be warmed in the least aggressive manner that will adequately treat their clinical situation. Hypothermia due to underlying disease carries a high mortality rate, as does the onset of ventricular fibrillation.

Age Factors↗

PubMed1993

Antiepileptic medication interactions.

This overview of AEM interactions underscores the importance of understanding the pharmacokinetic properties of AEMs and demonstrates the need for careful analysis of AEM concentrations in situations in which combinations of AEMs are used. Although generalizations concerning the clinical significance of drug interactions can be made, major interpatient variations occur. Thus, whenever an AEM is added or deleted, concentrations of drugs should be measured. Refractory individuals or those with multiple seizure types may need polypharmacy, and, under these circumstances, both total and unbound concentrations may need to be measured. New AEMs may have the potential for clinically significant interactions. If these are not identified and understood early, the development and ultimate clinical usefulness of these new agents may be inhibited.

Animals↗

PubMed1993

Current and future HIV/AIDS clinical research. HIV-related therapy improving--slowly.

More than 300,000 cases of AIDS have been reported in the United States since 1981. Despite major scientific advances and much effort, the benefits of treatment have been modest. The variable nature of the human immunodeficiency virus (HIV) and the complexity of the immune system are the major obstacles to advances in treatment. This article summarizes the current state of clinical research in pursuit of improved HIV therapy and takes a look into the future of anti-HIV therapeutics. It also provides an overview of HIV clinical research underway in Minnesota. Research efforts to improve therapy of HIV-induced immune deficiency will involve three strategies: better anti-HIV drugs and combinations of drugs aimed at slowing the replication of HIV, immune-based therapies intended to stimulate the immune system, and multiple opportunistic pathogen prophylaxis strategies to prevent HIV-related opportunistic infections. This approach will involve considerable cost and polypharmacy. Improvements in HIV/AIDS therapy are likely to occur incrementally, but the endeavor needs widespread support from patients, physicians, and the public. For now, the best strategy is prevention, which is where physicians can have the greatest impact on the epidemic.

AIDS-Related Opportunistic Infections↗

PubMed1994

Dangerous brew.

Polypharmacy, the use of multiple medications concurrently, is common among the elderly. Beers and Ouslander report that older North Americans consume 4.5 medications on average at any one time. In Canada, seniors take 25 per cent of all prescriptions but comprise only 12 per cent of the population. And according to Cartwright, 50 per cent of Britain's seniors take two or more medications on a regular basis.

Aged↗

PubMed1993

[The EEG background activity in children with epilepsy--effects of the removal of anticonvulsants on the EEG].

The development of the EEG background activity is generally impaired in children with epilepsy. Antiepileptic drugs (AEDs) are one of the important factor which influence the EEG background activity. We studied the effect of AEDs on the EEG. Subjects were 46 normal children and 48 children with epilepsy aged 5 to 15, who had not any organic brain damage and showed normal psychomotor development. Forty children with epilepsy (CBZ; 30 cases, VPA; 10 cases) had been on monopharmacy and 8 cases on polypharmacy. All of them have outgrown their epilepsy. The serial EEGs were recorded during withdrawal and after discontinuation of AED in each patient. These records were evaluated using computerized power spectral analysis. CBZ reduction associated with a decrease in delta and theta powers and an increase in alpha-2 power, which were also observed at VPA reduction in concomitant AEDs (VPA+CBZ). No parameter changed by VPA reduction in monopharmacy. The slowing of the EEG background activity was noticed even after discontinuation of CBZ. It required more time after discontinuation of CBZ in younger children than older before the EEG background activity became normal controls. These findings suggested that CBZ had a adverse effect, which was more remarkable in younger children than older children, on the development of EEG background activity and that the effect of CBZ on EEG was different from that of VPA.

Adolescent↗