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Biomedical subjects

R I Shorr

Publications and source records attributed to R I Shorr.

At least 37 records · Page 2Linked to original sources
PubMed1995

Prior head injury in male veterans with borderline personality disorder.

This study evaluated the relationship between traumatic brain injury (TBI) and borderline personality disorder (BPD). Forty-three males with BPD were compared with 49 age- and sex-matched controls with other psychiatric diagnoses. The occurrence of TBI was identified by chart review. Head injury was identified in 42% of patients meeting criteria for BPD but in only 4% of controls (p < .001). All patients but one had sustained a TBI prior to the diagnosis of BPD. The prevalence of TBI is higher in subjects with BPD than in controls. Since TBI occurred prior to the full expression of the BPD clinical syndrome, TBI appears to be a cause rather than the result of BPD.

Adult↗
PubMed1994

Changes in antipsychotic drug use in nursing homes during implementation of the OBRA-87 regulations.

OBJECTIVES: To describe the changes in antipsychotic drug use in nursing homes during the period surrounding the implementation of federal legislation designed to reduce unnecessary use (the Omnibus Budget Reconciliation Act of 1987 [OBRA-87]) and to identify nursing home characteristics associated with such changes. DESIGN: Longitudinal study of 9432 Tennessee Medicaid enrollees 65 years of age or older who continuously resided in Tennessee from April 1, 1989, to September 30, 1991, a 30-month period surrounding implementation of OBRA-87. MAIN OUTCOME MEASURES: Changes in the use of antipsychotic and other psychotropic drugs. RESULTS: During the 30-month period, antipsychotic drug use decreased from 23.9 to 17.5 days per 100 days of residence, a 26.7% decline (P < .001), which resulted from both a decrease in new users (P < .001) and a reduction in long-term use of antipsychotic drugs (P < .001). There was no concomitant increase in other psychotropic drug use. A multivariate analysis revealed that changes in antipsychotic use were strongly associated with baseline antipsychotic use (P = .001) and third-shift staffing levels (P = .003). Nursing homes with baseline antipsychotic drug use and third-shift staffing above the median reduced antipsychotic drug use by 41%, compared with a 2% increase in nursing homes where both of these factors were below the median (P < .0001). CONCLUSIONS: A substantial decrease in antipsychotic drug use coincided with the implementation of OBRA-87. Although this decrease is consistent with an improvement in quality of nursing home care, further research is needed to determine the effects of this legislation on resident outcomes.

Aged↗
PubMed1994

Rational use of benzodiazepines in the elderly.

In the 40 years since the introduction of benzodiazepines into clinical practice, considerable controversy has surrounded their use. While there is little evidence to suggest widespread abuse or long term use in most age groups, benzodiazepines continue to be widely prescribed to older adults in both community and long term care settings. Several studies have described an increased sensitivity to the clinical effects and toxicity of benzodiazepines in older adults. However, it is unclear whether these observations are attributable to age-related changes in benzodiazepine pharmacokinetics or pharmacodynamics. Benzodiazepines are the safest and most effective agents available for the pharmacological management of symptoms of anxiety and insomnia. However, the acute administration of benzodiazepines is associated with impairments in cognition, memory, coordination and balance, and long term use, even at therapeutic dosages, has been associated with symptoms of withdrawal upon abrupt discontinuation. Therefore, it is essential that the practitioner develop a treatment plan when utilising these agents to treat older patients. This plan may also involved the implementation of psychotherapy or other nonpharmacological modalities in the management of anxiety or insomnia. Although we recommend initiating benzodiazepines using the lowest available dosage, older patients should be treated with enough drug to produce a therapeutic response. For most clinical situations of anxiety or insomnia, we recommend prescribing limited quantities (e.g. a 2-week supply with a return visit for re-evaluation of effectiveness and adverse effects) of a drug with a short elimination half-life. Persistent anxiety or insomnia in the elderly may require a medical and possibly psychiatric evaluation. If benzodiazepines are used continuously for 6 weeks or longer, we recommend a gradual taper over 2 to 12 weeks with frequent follow-up to evaluate for signs of withdrawal or the return of symptoms.

Aged↗
PubMed1993

Concurrent use of nonsteroidal anti-inflammatory drugs and oral anticoagulants places elderly persons at high risk for hemorrhagic peptic ulcer disease.

BACKGROUND: Although joint use of nonsteroidal anti-inflammatory drugs (NSAIDs) and oral anticoagulants may increase the risk of gastrointestinal tract hemorrhage in elderly persons, no epidemiologic studies have been performed to quantify this risk. METHODS: We performed a retrospective cohort study of Tennessee Medicaid enrollees aged 65 years or older from 1984 through 1986. A total of 103,954 individuals contributed 209,066 person-years of follow-up, including 2203 person-years of current oral anticoagulant use, to the study. RESULTS: Of the cohort members, 1371 had confirmed hospitalizations for peptic ulcer disease. Of these, 661 (48%) presented with frank hematemesis or melena and thus met the definition for hemorrhagic peptic ulcer disease. Among current users of oral anticoagulants, the adjusted incidence of hospitalization for peptic ulcer disease was 14.3 per 1000 person-years, and the adjusted incidence of hospitalization for hemorrhagic peptic ulcer disease was 10.2 per 1000 person-years. Compared with nonusers, current anticoagulant users were at increased risk for hospitalization for ulcer disease (relative risk, 2.2; 95% confidence interval, 1.6 to 3.1), primarily due to the increased risk of hospitalization for hemorrhagic ulcers (relative risk, 3.3; 95% confidence interval, 2.3 to 4.9). Compared with nonusers of either drug, the relative risk of hemorrhagic peptic ulcer disease among current users of both anticoagulants and NSAIDs was 12.7 (95% confidence interval, 6.3 to 25.7). However, the prevalence of NSAID use among anticoagulant users was 13.5%, the same as in those who were not using anticoagulants. CONCLUSIONS: The nearly 13-fold increase in the risk of developing hemorrhagic peptic ulcer disease in concurrent users of oral anticoagulants and NSAIDs suggests that NSAIDs should be prescribed with extreme caution in patients undergoing anticoagulation therapy.

Administration, Oral↗
PubMed1993

Reserpine reconsidered: no association with serious peptic ulcer disease.

A history of peptic ulcer disease is frequently cited as a contraindication to the use of reserpine. However, the risk of ulcer disease associated with the use of reserpine at current therapeutic doses is unknown. To address this question, the authors conducted a nested case-control study of the association between reserpine use and hospitalizations for peptic ulcer disease in elderly Tennessee Medicaid enrollees. When compared with that of nonusers of reserpine, the relative risk of hospitalization for peptic ulcer disease was 0.8 (95% CI, 0.6-1.0) among current users and 0.8 (95% CI, 0.5-1.3) among former users. The authors' data provide evidence that reserpine is not associated with ulcer disease in elderly persons and suggest that a history of ulcer disease need not be a contraindication to the use of this drug.

Aged↗
PubMed1993

Medications and the older driver.

Table 4 provides a summary of the evidence that specific medications adversely affect the safety of the older driver. The preponderance of evidence suggests that benzodiazepines adversely affect the safety of the older driver, particularly for high doses and long half-life compounds. This conclusion is based upon the very consistent psychomotor function data showing pronounced dose-related impairment, the more limited epidemiologic data on crash involvement, epidemiologic data associating benzodiazepines with other types of injuries, and the fact that the reasons for most benzodiazepine use are not plausible confounders. This conclusion thus reinforces the need to prescribe benzodiazepines cautiously, including assessment of nonpharmacologic alternatives, use of the lowest possible dose for the shortest possible time, and avoidance of the very long half-life compounds. As more new nonbenzodiazepine anxiolytics and hypnotics become available, their effects on the safety of the elderly driver need to be determined. There is some evidence that cyclic antidepressants, currently the mainstay for treatment of depression in the elderly population, adversely affect driving safety; however, because of the paucity of experimental and epidemiologic data concerning the effects of depression per se on driving, further research is needed. Nevertheless, the existing data reinforce the need for careful prescribing of antidepressants, particularly avoidance of agents with high side-effect profiles (such as amitriptyline and imipramine) in the older driver. For hypoglycemics, although there is sufficient evidence of driving impairment to create a basis for concern, there are many unresolved questions. Currently, diabetic patients should be advised concerning the risk and management of hypoglycemia. For other sedating drugs, it always is prudent to advise patients concerning potential effects on driving. Unlike younger drivers, the typical older driver is a medication-taker. There now is a substantial body of evidence that commonly used medications can interfere with driving safety. Because many questions remain unanswered, there is a pressing need for further research that more fully elucidates how patient characteristics, disease, and drugs interact to affect driving safety; however, sufficient data are available to reinforce an underlying theme in geriatric medicine that is not yet fully implemented in practice: the need for caution in pharmacotherapy, with selection of a drug, dose, and regimen suitable for the unique characteristics of this population.

Aged↗
PubMed1992

Diagnosis and treatment of outpatient insomnia by psychiatric and nonpsychiatric physicians.

Insomnia is commonly encountered in general medical practice, but little is known about how primary care physicians manage this problem. We reviewed medical records describing 536 patient encounters in which either triazolam (Halcion) or flurazepam (Dalmane) was prescribed for outpatient use. Only 12% of the progress notes written by internists or surgeons contained even a remote reference to sleep, whereas 74% of psychiatrist's notes contained at least some sleep symptom documentation. In a multivariate analysis including the number of medical and psychiatric diagnoses, patient age, and physician gender, only the prescriber department was independently associated with the presence of symptom documentation. We also found that 30% of the prescriptions written by internists or surgeons were for inappropriately large quantities of these drugs (180 or more doses) compared with 6% of the prescriptions written by psychiatrists. We conclude that the evaluation of insomnia by nonpsychiatrists is often incomplete and that hypnotic drugs may be inappropriately prescribed by these physicians. Further efforts are needed to improve the management of insomnia by primary care physicians in the outpatient setting.

Disease↗
PubMed1992

Opioid analgesics and the risk of hip fracture in the elderly: codeine and propoxyphene.

We studied the risk of hip fracture in elderly persons receiving prescriptions for two commonly prescribed opioid analgesics--codeine and propoxyphene. Using automated prescription and hospitalization data, we identified 4,500 residents of Saskatchewan, Canada, aged 65 or older, who sustained a hip fracture between 1977 and 1985, and 24,041 age- and sex-matched controls. Compared to nonusers, the relative risk (95% CI) of hip fracture in current users of codeine or propoxyphene was 1.6 (1.4-1.9). There was no difference between relative risks of fracture among current users of codeine [1.6 (1.3-1.9)] and propoxyphene [1.6 (1.2-2.2)]. In new users of these opioids, the relative risk of fracture was 2.2 (1.7-2.8), compared to 1.3 (1.0-1.6) in users who received at least one additional prescription for codeine or propoxyphene in the 90-day period prior to the index date. Concurrent users of these opioids and psychotropic drugs (sedatives, antidepressants, or antipsychotics) had a risk of fracture 2.6 (2.0-3.4) times that of nonusers of either drug class. Review of a sample of medical records for 701 cases suggested this finding was not due to confounding by body mass, ambulatory status, functional status, or dementia. Given the essential role of opioids in the management of pain in geriatric practice, further study is needed to determine the psychomotor effects of opioid analgesics in older adults.

Age Factors↗
PubMed1990

Failure to limit quantities of benzodiazepine hypnotic drugs for outpatients: placing the elderly at risk.

PURPOSE: The long-term use of benzodiazepine hypnotics by the elderly is associated with serious side effects, and prescriptions of large quantities of these agents allow such use. Therefore, we determined the quantities of these agents prescribed to outpatients in our Veterans Administration teaching hospital, and the relationship of patient age to total number of doses prescribed per prescription. PATIENTS AND METHODS: Pharmacy and patient records related to 655 consecutive prescriptions for triazolam (Halcion) and flurazepam (Dalmane) were reviewed. Only 266 (41%) of the prescriptions were for 30 or fewer doses, while 178 (27%) were written for 180 or more doses. RESULTS: Thirty-six percent of prescriptions for patients aged 65 years or older were for 180 or more doses, compared with 24% for those aged 45 to 64 years old, and 16% of the prescriptions for patients less than 45 years old (p less than 0.0001). In a multivariate analysis controlling for six other factors related to the total number of doses prescribed, patients aged 65 years or older were still more likely to receive a prescription for 180 or more doses (relative risk 1.9, 95% confidence interval 1.3, 2.8). CONCLUSION: We conclude that inappropriately large quantities of benzodiazepine hypnotics were commonly prescribed, and that patients aged 65 years or older were at greatest risk for receiving such prescriptions.

Age Factors↗
PubMed1990

Effects of patient age and physician training on choice and dose of benzodiazepine hypnotic drugs.

We conducted a cross-sectional review of all prescriptions (N = 554) for triazolam and flurazepam hydrochloride written by nonpsychiatrists to outpatients at a university affiliated Veterans Administration hospital. We sought to determine whether triazolam, an agent with a short half-life, was used preferentially in older patients (age greater than or equal to 70 years). We also wanted to determine whether dosages of triazolam or flurazepam were lowered in elderly patients. Our findings showed that prescriber level of training was a much stronger determinant of drug choice than patient age. Attending physicians prescribed flurazepam twice as often as interns. Lower dosages of both agents were prescribed more frequently to older patients. Our data suggest that some physicians choose a benzodiazepine hypnotic out of habit rather than application of pharmacologic principles, but reduce doses appropriately when prescribing to elderly patients.

Age Factors↗
PubMed1985

In vitro effects of acetaminophen and its analogues on human platelet aggregation and thromboxane B2 synthesis.

We examined the effect of acetaminophen and the structural analogues 2,6-dimethylacetaminophen, 3,5-dimethylacetaminophen, and N-acetyl-p-benzoquinone imine on human platelet aggregation, 14C-serotonin secretion, and thromboxane B2 synthesis. Preincubation with 1 mM acetaminophen for 2 min completely inhibited arachidonic acid- and collagen-stimulated platelet aggregation. Thromboxane B2 production and 14C-serotonin secretion by arachidonic acid-stimulated platelets also were completely inhibited. Preincubation of platelets with 1 mM 3,5-dimethylacetaminophen inhibited collagen and arachidonic acid-induced aggregation and arachidonic acid-stimulated thromboxane B2 synthesis, while treatment with 2,6-dimethylacetaminophen did not inhibit aggregation and blocked thromboxane B2 formation to a much lesser degree. Preincubation with 1 mM N-acetyl-p-benzoquinone imine inhibited arachidonic acid-induced aggregation and 14C-serotonin secretion but had no effect on arachidonic acid-induced thromboxane B2 formation and collagen-induced platelet aggregation.

Acetaminophen↗