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PubMed1995

Drug use in the nursing home.

Some of the most intensive pharmacotherapy today occurs in nursing homes in very complex and vulnerable patients. The nursing home provides an opportunity for highly effective drug use, but it also presents risks for polypharmacy and adverse events. Nursing homes are complex social institutions, in which physicians, nurses, consultant pharmacists, other health care professionals, aides, and administrators must interact to make decisions about drug use for patients who generally are frail and have numerous comorbid conditions. Federal regulations have recently been implemented to direct the ways in which specific drugs are to be used in this setting. The nursing home environment can present an ideal opportunity for comprehensive drug regimen review, an exercise too often neglected in the care of elderly patients in all clinical settings. Psychoactive medications, analgesics, and laxatives are examples of drugs that should receive such review. The possible underuse of drug therapies that may be beneficial to nursing home residents, including antidepressant, antihypertensive, and antithrombotic agents; calcium supplements; and vaccines, must be further quantified and must receive increased attention. Morbidity and functional incapacity can be substantially reduced by applying currently established principles of geriatric pharmacology in the nursing home setting, but enormous gaps still exist in the knowledge base necessary to guide this aspect of geriatric medical practice. Data on the efficacy, toxicity, and cost-effectiveness of pharmacotherapeutic choices in nursing home patients are in short supply; considerably more clinical and epidemiologic research is needed to define the relations between the benefits and risks of drugs for this unique population.

Drug Utilization↗
PubMed1997

Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians.

PURPOSE: To review the literature on diagnostic testing in syncope and provide recommendations for a comprehensive, cost-effective approach to establishing its cause. DATA SOURCES: Studies were identified through a MEDLINE search (1980 to present) and a manual review of bibliographies of identified articles. STUDY SELECTION: Papers were eligible if they addressed diagnostic testing in syncope or near syncope and reported results for at least 10 patients. DATA EXTRACTION: The usefulness of tests was assessed by calculating diagnostic yield: the number of patients with diagnostically positive test results divided by the number of patients tested or, in the case of monitoring studies, the sum of true-positive and true-negative test results divided by the number of patients tested. DATA SYNTHESIS: Despite the absence of a diagnostic gold standard and the paucity of data from randomized trials, several points emerge. First, history, physical examination, and electrocardiography are the core of the syncope workup (combined diagnostic yield, 50%). Second, neurologic testing is rarely helpful unless additional neurologic signs or symptoms are present (diagnostic yield of electroencephalography, computed tomography, and Doppler ultrasonography, 2% to 6%). Third, patients in whom heart disease is known or suspected or those with exertional syncope are at higher risk for adverse outcomes and should have cardiac testing, including echocardiography, stress testing. Holter monitoring, or intracardiac electrophysiologic studies, alone or in combination (diagnostic yields, 5% to 35%). Fourth, syncope in the elderly often results from polypharmacy and abnormal physiologic responses to daily events. Fifth, long-term loop electrocardiography (diagnostic yield, 25% to 35%) and tilt testing (diagnostic yield < or = 60%) are most useful in patients with recurrent syncope in whom heart disease is not suspected. Sixth, psychiatric evaluation can detect mental disorders associated with syncope in up to 25% of cases. Seventh, hospitalization may be indicated for patients at high risk for cardiac syncope (those with an abnormal electrocardiogram, organic heart disease, chest pain, history of arrhythmia, age > 70 years) or with acute neurologic signs. CONCLUSIONS: Many tests for syncope have a low diagnostic yield. A careful history, physical examination, and electrocardiography will provide a diagnosis or determine whether diagnostic testing is necessary in most patients.

Algorithms↗
PubMed1976

Suggestions for a rational aproach to the chemotherapy of schizophrenia.

Current psychiatric practice does not seem to have kept pace with the best recommendations of modern clinical psychopharmacology. Polypharmacy, inadequate dosage, overly brief drug trails, and erratic medication changes are commonplace. Psychopharmacology is obligated to disseminate the most current thinking in usuable form and psychiatry to attempt to implement it in clinical practice. Unique here is the concept that there are pharmacologic, theoretical, and technical reasons to prefer the use of high potency neuroleptics for the routine treatment of schizophrenia and to relegate low potency drugs to secondary status. Routine employment of higher standard neuroleptic doses is advanced to minimize the effects of individual variations in compliance, absorption, and metabolism. A suggested protocol for the acute treatment of schizophreniform disorders is offered.

Antiparkinson Agents↗
PubMed1999

Mechanisms and significance of inhibitory drug interactions involving cytochrome P450 enzymes (review).

The cytochrome P450 (CYP) superfamily of enzymes are catalytically competent toward an unusually diverse array of lipophilic chemicals. The major microsomal CYP in human liver, CYP3A4, participates in the oxidative biotransformation of most drugs. Accordingly, it is not surprising that CYP activity is also readily inhibited by many drugs. Such interactions may elicit adverse toxic effects in patients and this situation is exacerbated by the practise of polypharmacy. Clinical studies have suggested that the judicious selection of drugs for combination therapy may be a relatively simple means by which drug interactions can be avoided. Such studies will rely heavily on basic information obtained from biochemical studies that describe the substrate preferences of CYPs and molecular studies on the factors that determine CYP levels in subjects. This review focuses on the information that is emerging on CYP substrate and inhibitor specificity, protein structure from homology modelling approaches and CYP expression in liver as it emerges from molecular analyses. With information of this type, drawn from several different sources, it will eventually be possible to reconcile the likelihood of drug interactions produced by specific combinations of drugs and predict those individuals who are at risk from such interactions, as a consequence of their genetic makeup.

Animals↗
PubMed1994

Patient information: community pharmacy needs and perspectives.

Providing complete and understandable information to patients about medicines is considered an integral component of high-quality medical and pharmaceutical care. With such information, not only can the level of general health increase, but costs associated with noncompliance, including polypharmacy and hospitalization, can decrease. Although patient information leaflets (PILs) have been available since the 1970s, their use is more relevant today because of the counseling requirements of the Omnibus Budget Reconciliation Act of 1990. A national survey of community pharmacists was conducted to determine their attitudes toward this patient education strategy. Results demonstrate that pharmacists believe PILs benefit patients, but that PILs need revision in terms of readability, understandability, and standardization.

Attitude of Health Personnel↗
PubMed1995

Characterization of drug-related problems in elderly patients on admission to a medical ward.

The incidence, types, avoidability and risk factors associated with drug-related problems (DRPs) in geriatric patients on admission to a medical ward of the Toronto Hospital were assessed. The admission note and laboratory data of 150 consecutive admissions were reviewed for the presence of an adverse drug reaction, inappropriate dose, non-compliance, drug interaction, or lack of required medication. The avoidability (avoidable, possibly avoidable, or unavoidable) and contribution to hospitalization (major reason, contributing or non contributing) of each DRP was characterized. On admission, 41% of patients had a DRP identified, of which most were potentially avoidable (96.8%) and involved commonly prescribed drugs. The DRP was the major or contributing reason for admission in 31% of cases. Polypharmacy was a statistically significant risk factor for a DRP, particularly for male patients (p = 0.0010). In this elderly population, DRPs were not statistically correlated to age greater than 65 years, gender, renal function, native language, or duration of hospital stay. The incidence of DRPs and hospitalizations in the elderly can potentially be reduced by improving medication use. Enhanced communication, particularly between hospital and community pharmacists and their patients, may be a key mechanism.

Aged↗
PubMed1984

Computer-based prescription audit as a research, educational and management tool.

An existing dedicated pharmacy computer system (MIDAS system, Alfred Hospital and Health Computing Services, Victoria) used primarily for pharmacy labelling and dispensing, has been rewritten for an in-house minicomputer, with enhancements that allow it to be used in budgetary predictions, drug use monitoring, therapeutic audit and as a research tool. An automatically updated hard copy record of individual patient prescription profiles is generated and represents a valuable addition to the patient medical record. Allied to automatic "sorting" and retrieval techniques, all patients on nominated drugs can be identified and their records examined for particular combination use. Current application to assessment of nifedipine- beta blocker use will be presented, as will an application to cimetidine audit. Prescriptions can be scanned and segregated in terms of numbers of prescriptions in addition to segregation in terms of a particular therapeutic agent. Initial application to audit has detected an unacceptable level of polypharmacy (more than 26% of all prescriptions involve greater than or equal to 5 items and more than 3% involved greater than or equal to 10 items). Statistical information on the volume and unit cost of outpatient prescribing allows a precise estimate of ongoing budgetary commitments, while trends in discharge medication profiles allow a basis for prediction of budgetary trends, particularly with respect to the use of recent additions to the formulary. The system allows for expansion at minimal cost with potentially revolutionary applications, for example, interactive prescriber education if and when "on-line" capabilities are developed. Cross-linking with relevant data-bases will allow a major expansion of applied research into therapeutic drug use and its consequences.

Australia↗
PubMed1999

Psychoses in the elderly: a spectrum of disorders.

The incidence of psychoses increases with age with a number of factors leading to the increase in vulnerability and expression. They include comorbid physical illnesses, social isolation, sensory deficits, cognitive changes, polypharmacy, and substance abuse. Agitation and aggressiveness are also associated with psychosis in the elderly and frequently are the precipitating reasons for psychiatric consultation. A review of psychoses in the elderly must, therefore, consider psychotic symptoms within the context of the underlying etiologies of the psychotic symptoms. Elderly patients who present with psychotic symptoms require social, behavioral, and environmental interventions that are necessary for their safety and orientation. Given the likelihood of comorbid medical disorders and concomitant medications, the mere presence of delusions or hallucinations is not always an indication for additional medications. However, some patients may need pharmacologic intervention in order to manage the behavioral disturbance that often results from the psychotic symptoms. The atypical antipsychotics with their low propensity to produce extrapyramidal and cognitive side effects have greatly advanced the pharmacotherapy for elderly patients with psychoses.

Aged↗
PubMed1999

Recognizing the early stages of dementia.

Dementia is the most common psychiatric problem seen in the elderly, a steadily growing patient group. Cognitive impairment may be difficult to recognize, particularly in early phases, being mistaken for depression, hypochondriasis, or other conditions. Early, correct diagnosis of dementia reduces cases of inappropriate treatment and polypharmacy, and increases likelihood of improving quality of life.

Aged↗
PubMed1999

Side effects of pharmaceuticals not elicited by comparable herbal medicines: the case of tetrahydrocannabinol and marijuana.

OBJECTIVE: Herbalists claim that the polypharmacy of botanical remedies provides 2 advantages over single-ingredient drugs: (1) primary active ingredients in herbs are synergized by secondary compounds, and (2) secondary compounds mitigate the side effects caused by primary active ingredients. To examine this second claim, medical marijuana was compared with its primary active ingredient, tetrahydrocannabinol. DATA SOURCES: A search on MEDLINE (1966-1999), AGRICOLA (1990-1999), and Biological and Agricultural Index (1964-1999) using keywords "cannabinoids," "marijuana," "tetrahydrocannabinol," "Cannabis," and "hemp." Phytochemical and ethnobotanical data were searched with the Agricultural Research Service database. Unindexed botanical journals were scanned by hand. STUDY SELECTION: Studies documenting the efficacy of secondary compounds mitigating side effects of tetrahydrocannabinol consisting of double-blind trials, unblinded studies, animal models, and in vitro experiments. DATA EXTRACTION AND DATA SYNTHESIS: Data validity was assessed by consensus, weighted by source (peer-reviewed article vs popular press), identification methodology (analytical chemistry vs clinical history), and frequency of independent observations. CONCLUSIONS: Good evidence suggests that some side effects of tetrahydrocannabinol are mitigated by other volatile compounds present in the essential oil of marijuana. Inhaling tetrahydrocannabinol, which avoids first-pass hepatic metabolism, has advantages over ingesting it. Other cannabinoids, terpenoids, and flavonoids can reduce tetrahydrocannabinol-induced anxiety, cholinergic deficits, and immunosuppression. Other compounds increase cerebral blood flow, enhance cortical activity, kill respiratory pathogens, and provide anti-inflammatory activity. The hazards of marijuana smoke can be reduced with appropriate technology. Proprietary Cannabis extracts containing a mixture of cannabinoids, terpenoids, and flavonoids are currently being developed and tested.

Analgesics, Non-Narcotic↗
PubMed1999

[Evaluation of allergic-type reactions to antibiotics and rapid immunotherapy].

Adverse effects of medications, most notably antimicrobials, are becoming increasingly common and raise difficult challenges in the area of clinical pattern definition (wide variety of symptoms, polypharmacy in many cases), diagnosis, and methodology (need for a rapid diagnosis, frequent obscurity of causative mechanisms, and less than ideal reliability of laboratory techniques). Sixty patients were treated by rush immunotherapy to one or more antimicrobials. The pretreatment evaluation included oriented history taking, skin tests, blood cell counts, IgE assays, and cell activation tests (basophils and lymphocytes). The results of this study confirm the usefulness of skin tests (intradermal, prick, or patch tests), which provided etiological orientation in 54 of the 60 cases. They also provide additional evidence of the lack of reliability of currently available in vitro tests (only 29 of the 60 tests were positive).

Anti-Bacterial Agents↗
PubMed1999

Care of depressed patients with anxiety symptoms.

Anxiety frequently coexists with depression, either as a comorbid anxiety disorder or as anxiety symptoms accompanying a primary depressive disorder. Effective therapy for the treatment of depressive illness must include a consideration of anxiety symptoms, since anxiety has been estimated to be present in up to 96% of patients with depressive illness. Available data also indicate that depressed patients with significant anxiety may be at greater risk for suicide. Of particular clinical importance are symptoms of somatic anxiety: they are present in up to 86% of depressed patients, and the failure to treat them effectively can diminish the ability of a patient to function. Since the overall prognosis for recovery from a major depressive episode is less than optimal in patients with significant anxiety, treatments that can provide an effective and early relief of both depressive and anxiety symptoms are of paramount importance. Drugs with serotonin reuptake inhibition (such as selective serotonin reuptake inhibitors [SSRIs] or serotonin-norepinephrine reuptake inhibitors [SNRIs]) may produce transient increases in anxiety symptomatology presenting as jitteriness, agitation, insomnia, and gastrointestinal symptoms when treatment is initiated. Mirtazapine has intrinsic receptor-blocking properties (in particular, serotonin-2 [5-HT2] receptor blockade) that can be linked to an early relief of anxiety symptoms during the treatment. The available data show that mirtazapine is superior to placebo in depressed patients with high baseline anxiety and/or agitation. Furthermore, mirtazapine was statistically significantly superior to both citalopram and paroxetine in alleviating anxiety symptoms early in treatment as assessed by changes from baseline on the Hamilton Rating Scale for Anxiety or the Hamilton Rating Scale for Depression anxiety/somatization factor, respectively. Mirtazapine provides early and effective relief of both depressive and anxiety symptoms, reducing the need for polypharmacy. These therapeutic actions of mirtazapine persist throughout the course of treatment.

Antidepressive Agents, Tricyclic↗
PubMed1999

Psychiatric emergencies: rapid response and life-saving therapies.

Mental status in older patients can be acutely affected by a range of factors, particularly polypharmacy, disorders of cognition, psychosis, and elder abuse. Patients so affected may be agitated, uncooperative, combative, suicidal, or incapable of participating in treatment decisions. In a life-threatening emergency, a patient may need to be restrained or a treatment administered against a patient's wishes. Key to successful management of psychiatric emergencies is an awareness of the potential scenarios, familiarity with appropriate interventions, and an understanding of patient rights. An increased alertness for life-threatening behaviors can help prevent an event from worsening and minimize the likelihood of a patient acting out on a threat of violence or suicide.

Aged↗
PubMed1999

The older patient: the ongoing challenge of efficacy and tolerability.

The clinical management of older schizophrenic patients presents particular clinical challenges. Antipsychotics are among the most widely prescribed class of medications for elderly patients. However, the increased frequency of chronic illnesses and thus the potential need for polypharmacy means that the most appropriate treatment strategy for the older schizophrenic patient is not easily extrapolated from the wealth of clinical trials conducted in younger patients. The development of atypical antipsychotics, with their lower propensity to cause adverse effects and cognitive impairment, offers considerable potential benefits to the older schizophrenic patient. The particular problems and key issues that should be addressed when selecting an appropriate antipsychotic for schizophrenic patients in this sensitive population, as well as the place of the new atypical antipsychotic agents in treating this population, are discussed.

Age Factors↗
PubMed2000

The geriatric patient: a systematic approach to maintaining health.

The number of persons 65 years of age and older continues to increase dramatically in the United States. Comprehensive health maintenance screening of this population is becoming an important task for primary care physicians. As outlined by the U.S. Preventive Services Task Force, assessment categories unique to elderly patients include sensory perception and injury prevention. Geriatric patients are at higher risk of falling for a number of reasons, including postural hypotension, balance or gait impairment, polypharmacy (more than three prescription medications) and use of sedative-hypnotic medications. Interventional areas that are common to other age groups but have special implications for older patients include immunizations, diet and exercise, and sexuality. Cognitive ability and mental health issues should also be evaluated within the context of the individual patient's social situation-not by screening all patients but by being alert to the occurrence of any change in mental function. Using an organized approach to the varied aspects of geriatric health, primary care physicians can improve the care that they provide for their older patients.

Accidental Falls↗
PubMed1999

Psychotropic drugs prescriptions in Al-Qassim region, Saudi Arabia.

Psychotropic drugs prescriptions for patients attending psychiatric outpatient clinics were studied. Of the 52,168 prescriptions written in 1996, 18,265 were systematically, randomly selected and evaluated. Incomplete prescriptions were found; the data missing included duration of treatment (18.75%), sex (9.25%), age (8.75%) and diagnosis (7.50%). Antipsychotics (33.1%), antidepressants (23.2%), anticholinergics (22.0%) and anticonvulsants (12.9%) were the most frequently prescribed drugs. Polypharmacy (85%) was the predominant mode of practice. The most common diagnoses were mood (23.1%), anxiety (17.7%) and schizophrenic (16.2%) disorders. Medical education and quality monitoring programmes are suggested to improve the quality of psychotropic prescriptions and modify multiple pharmacotherapy practice.

Drug Prescriptions↗
PubMed2000

Side effects of antipsychotics in the elderly.

Side effects of antipsychotic medications are particularly problematic in elderly patients, who experience many age-related changes that may exacerbate medication side effects. Side effects of particular concern in the elderly include anticholinergic reactions, parkinsonian events, tardive dyskinesia, orthostatic hypotension, cardiac conduction disturbances, reduced bone mineral density, sedation, and cognitive slowing. In addition, elderly patients with schizophrenia often have comorbid medical illnesses-such as cardiovascular disease and dementia of the Alzheimer's type-and are thus likely to be taking multiple medications. The effects of polypharmacy must be carefully considered. Patients, caregivers, and family often have different perspectives on side effects. This article addresses the side effects of the currently available antipsychotic medications in light of these concerns.

Age Factors↗
PubMed2000

[Detection and evaluation of adverse drug effects].

Adverse drug reactions (ADRs) occur in about 5% of drug-treated patients. Hospital admissions are caused by ADRs in 5% of patients and roughly 2% of hospitalized patients will experience an ADR. The economic burden of ADRs can only be estimated. Type A reactions can be explained by the pharmacological action of the drugs, and are preventable in many cases. However, Type B reactions involving the immune system and/or idiosyncratic reactions occur rarely and most of them are not fully understood. Genotyping represents an elegant method to explain the presence of abnormal enzyme activities and allows prediction of adverse drug effects in individual cases. Typical time frames have been identified for the occurrence of hypersensitivity reactions, although definite causality assessment is often impeded due to the absence or unavailability of specific laboratory tests and the impossibility of rechallenge. Diagnosis of an ADR is often difficult due to comorbidity and polypharmacy, thus causality assessment is often divergent even between specialists. In Germany, ADRs are reported preferably to the manufacturer of the suspicious drug and then collected and evaluated at the Bundesinstitut für Arzneimittel und Medizinprodukte, BfArM. However, total number and quality of reported ADRs could be improved.

Adverse Drug Reaction Reporting Systems↗