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PubMed2004

Malnutrition in the institutionalized elderly: the effects on wound healing.

Under-nutrition and protein-energy malnutrition are seen at alarmingly high rates in institutionalized elderly and in patients admitted to hospitals. A combination of immobility and loss of lean body mass - which comprises muscle and skin - and immune system challenges increases the risk of pressure ulcers by 74%. The development of pressure ulcers in the hospital affects 10% of admissions, with the elderly at the highest risk. Common causes of malnutrition in the elderly involve: decreased appetite, dependency on help for eating, impaired cognition and/or communication, poor positioning, frequent acute illnesses with gastrointestinal losses, medications that decrease appetite or increase nutrient losses, polypharmacy, decreased thirst response, decreased ability to concentrate urine, intentional fluid restriction because of fear of incontinence or choking if dysphagic, psychosocial factors such as isolation and depression, monotony of diet, and higher nutrient density requirements along with the demands of age, illness, and disease on the body. All have been found to delay healing and increase the risk of pressure ulcer development. In addition, what is ingested should contain nutrients to support health and healing. The financial impact of malnutrition is high and the consequences for patient morbidity and mortality are severe. Practical suggestions to improve the nutritional status of long-term care residents include liberalizing previous diet restrictions where safe and appropriate, addressing impairments to dentition and swallowing, addressing physical and/or cognitive deficits, encouraging family and friends to provide favorite foods, auditing/addressing specific food under-consumption, and providing prudent nutrient supplementation. Clinicians must be aware of the numerous factors in play with regard to nutrition and its impact on not only general well-being but also on wound care. Nutritional intervention in pressure ulcer management is truly "healing from the inside out."

Aged↗
PubMed2004

Medical therapy for obesity: present and future.

The prevalence of obesity worldwide has risen sharply during the last four decades. The etiology of obesity is complex and includes a host of genetic influences in addition to the overconsumption of energy coupled with a sedentary lifestyle. Obesity is known to cause or exacerbate many co-morbid conditions such as diabetes, hypertension, dyslipidemia, coronary heart disease, stroke, certain cancers, arthritis and obstructive sleep apnea. Modest weight losses of 5-10% of actual weight are related to significant improvements in co-morbid conditions, but unfortunately the rate of recidivism with short-term therapy for obesity is high. The recent recognition of obesity as a chronic disease that should be treated with long-term programs and possibly with polypharmacy, and the alarming increase in its prevalence, have prompted extensive research and the development of new pharmacotherapy.

Anti-Obesity Agents↗
PubMed2004

A review of fibromyalgia.

Characterized by chronic widespread joint and muscle pain, fibromyalgia is a syndrome of unknown etiology. The American College of Rheumatology's classification criteria for fibromyalgia include diffuse soft tissue pain of at least 3 months' duration and pain on palpation in at least 11 of 18 paired tender points. Symptoms are often exacerbated by exertion, stress, lack of sleep, and weather changes. Fibromyalgia is primarily a diagnosis of exclusion, established only after other causes of joint or muscle pain are ruled out. The initial workup for patients who present with widespread musculoskeletal pain should include a complete blood count, erythrocyte sedimentation rate, liver function tests, hepatitis C antibody, calcium, and thyrotropin. The musculoskeletal system, the neuroendocrine system, and the central nervous system, particularly the limbic system, appear to play major roles in the pathogenesis of fibromyalgia. The goal in treating fibromyalgia is to decrease pain and to increase function without promoting polypharmacy. Brief interdisciplinary programs have been shown to improve subjective pain. Fibromyalgia is a complex syndrome associated with significant impairment on quality of life and function and substantial financial costs. Once the diagnosis is made, providers should aim to increase patients' function and minimize pain. This can be accomplished through nonpharmacological ahd pharmacological interventions. With proper management, the rate of disability appears to be significantly reduced.

Central Nervous System↗
PubMed1992

Epilepsy and employment, marital, education and social status.

Employment, marital, educational and social status in epileptic patients attending a seizure clinic were assessed. A total of 343 patients were evaluated. The social group, employment and marital status did not compare favourably with the overall population. Forty per cent of patients belonged to social group five and six compared with 14% of the population. Thirty three per cent of male patients aged 20 years or more were married, compared with 65% in the community. The corresponding statistics for females were 46% and 73% respectively. The male unemployment rate of 34% compared poorly with the unemployment rate of 13% for the period during which the study data was collected. Patients with lower educational attainments were significantly more likely to have poor seizure control (P less than 0.001), or required polypharmacy. A similar situation was found between seizure control and social status, with poor seizure control occurring in patients in social group six.

Adolescent↗
PubMed2005

Irritable bowel syndrome. 10% to 20% of older adults have symptoms consistent with diagnosis.

Although irritable bowel syndrome (IBS) is a common disorder, IBS is traditionally considered to be a condition that primarily affects young and middle-aged adults. However, increasing evidence suggests that prevalence of IBS in older adults may be similar to that in younger adults; therefore, the diagnosis should be considered when a geriatric patient presents with unexplained abdominal symptoms. Because incidences of other conditions with similar symptoms are higher in the geriatric population, use of certain diagnostic tests (eg, colonoscopy) is warranted in this patient population. In addition, because older adults are more likely than younger adults to suffer from comorbid conditions, polypharmacy is common in this patient population, and this should be considered when diagnosing and treating these patients.

Aged↗
PubMed1992

Epilepsy, pregnancy, and major birth anomalies: an Italian prospective, controlled study.

We followed prospectively 97 women with epilepsy during 138 pregnancies and 88 women without epilepsy, matched for age, during 140 pregnancies. We evaluated seizure frequency, pregnancy outcome, and presence of major congenital malformations, and correlated them with the type of epilepsy, antiepileptic drugs (AEDs) implicated, plasma AED levels during pregnancy, and maternal age. We compared the two groups regarding type and number of pregnancies; complications during gestation, labor, and delivery; prevalence of abortions (spontaneous or induced); perinatal deaths; and type and prevalence of major malformations. No change in seizure frequency during pregnancy was seen in 79.7% of cases. Pregnancy complications and incidence of major congenital malformations were only slightly higher in women with epilepsy than in women without epilepsy. No single AED used as monotherapy correlated with increased risk of malformations, but polypharmacy with phenobarbital and phenytoin seemed to represent a risk factor. Low socioeconomic status, older age at delivery, and family history of malformations were other risk factors for neonatal malformations.

Abnormalities, Drug-Induced↗
PubMed2003

Household survey of treatment of malaria in Hajjah, Yemen.

The practice of self-medication is widespread in the Republic of Yemen. The objectives of this study were to describe the treatment of malaria in households and to promote rational treatment. We surveyed 201 households with family members suffering from malaria or being treated with antimalarials. Numbers of prescribed and non-prescribed drugs were recorded and treatment rationality assessed. Common patterns of irrational treatment of malaria were observed. Polypharmacy was common, with an average of 3.8 total drugs and 1.3 antimalarials found per encounter. Misused and over use of injectables antimalarials was common. People practised self-medication because of belief, experience, lack of confidence in health services and cost of treatment. Most had no knowledge concerning possible risks of antimalarials.

Antimalarials↗
PubMed1992

When outside the norm is normal: interpreting lab data in the aged.

Laboratory tests that are frequently ordered in a primary care practice include complete blood count, arterial blood gases, erythrocyte sedimentation rate, creatinine clearance, and glucose tolerance. Yet, the impact of age-associated physiologic changes on interpretation of laboratory data has only recently been elucidated. With advancing age, many laboratory parameters increase or decrease, some remain unchanged, and the effect of age on still others remains unclear. Interpreting lab data in the elderly is further confounded by the multiple disease states, polypharmacy, and atypical disease presentations commonly found in this population. Additional clinical research is needed to better establish reference laboratory values in elderly patients.

Aged↗
PubMed2005

Digoxin prescribing for heart failure in elderly residents of long-term care facilities.

BACKGROUND: Digoxin is often used in long-term care (LTC) residents with heart failure despite a high risk of toxicity associated with increased age, comorbidities and polypharmacy. This toxicity may occur at serum digoxin concentrations that are as low as 1.54 nmol/L. OBJECTIVES: To determine the prevalence of digoxin use, estimate the proportion at risk of toxicity and identify correlates of digoxin use in LTC residents with heart failure. METHODS: Cross-sectional survey in eight LTC facilities that lodge a total of 1223 residents. RESULTS: The prevalence of heart failure was 20%. Digoxin was prescribed for 32% of residents with heart failure and was associated with arrhythmia (primarily atrial fibrillation), anticoagulant and diuretic use, and higher serum thyroid-stimulating hormone. Digoxin doses higher than those that achieve the recommended therapeutic peak body stores of 6 microg/kg and 10 microg/kg were prescribed to 80% and 33% of residents with heart failure, respectively. Serum digoxin concentrations were greater than 1.5 nmol/L in 30% of patients. Comorbidities and concurrently prescribed medications that increase the risk of digoxin toxicity were prescribed to 26% of the patients. CONCLUSIONS: Approximately one-third of LTC residents with heart failure received digoxin. Atrial fibrillation was the most important determinant of use. At least 26% of these residents were exposed to an increased risk of digoxin toxicity. Studies are required to determine safe and effective digoxin dosing regimens for frail elderly heart failure patients. Clinicians should exercise caution when using digoxin in LTC residents.

Aged↗
PubMed2005

Safe and effective drug therapy in older adults.

The last two decades have witnessed the introduction of major advances in drug therapy for many chronic diseases. Despite an increasing number of therapeutic choices, basic challenges remain when using new drugs in the elderly. It isessential: (1) to consider whether a new drug is truly safer, more effective or worth the extra expense compared to established medications, (2) to monitor patients for drug related toxicities, and (3) to avoid polypharmacy and the prescribing cascade.

Aged↗
PubMedDate not supplied

Irrational drug use in India: a prescription survey from Goa.

BACKGROUND: There is concern regarding the irrational production, prescription and use of drugs in India. This study aimed to describe the quality of prescriptions by medical practitioners, including both the layout of the prescription and the type and number of drugs prescribed. MATERIALS AND METHODS: A survey of all prescriptions dispensed at a busy pharmacy in the state of Goa, India, was carried out over a consecutive seven-day period. Each prescription was rated on the basis of a priori and pilot-tested variable list. The prescriptions by private practitioners were compared with those from practitioners in the public healthcare system. RESULTS: Nine hundred and ninety prescriptions were collected. The majority (83.9%) were from private practitioners. The quality of the layout of the prescriptions was unsatisfactory: information to identify the practitioner was incomplete in more than a third of the prescriptions and information to identify the patient was incomplete in more than half. Clarity of written instructions on how to take the medicines was unsatisfactory in the majority of prescriptions. Polypharmacy was the norm, with more than half (52.7%) the prescriptions containing at least 3 medicines. Forty per cent of prescriptions included a vitamin or tonic preparation and a quarter of the prescriptions included an antibiotic and an analgesic. Over 90% of prescriptions contained only branded medicines. Private practitioners prescribed significantly greater number of medicines and were more likely to prescribe vitamins and antibiotics, and branded medicines. DISCUSSION: This study confirms that the quality of prescriptions, both in terms of layout and the content of the drugs prescribed, is inadequate. There is a need to standardize the format of prescriptions in India so that all essential information is included. There is a need to strengthen an independent mechanism for continuing professional development of practitioners to ensure that patients are always given evidence-based, cost-effective treatments.

Cross-Sectional Studies↗
PubMed2004

Quality use of medicines in the rural ambulant elderly: a pilot study.

INTRODUCTION: Australia has a rapidly ageing population, especially in rural areas, and strategies to address medicines and the elderly are particularly relevant. The aims of this 18 month study, therefore, were to: (1) determine the influence of a medication review on the quality of life of elderly ambulatory patients managed by a general practitioner; and (2) assess the impact of the medication review process on health outcomes such as medication-related hospital admissions in ambulant elderly patients actively managed by their GP. METHODS: The study was conducted within the area serviced by the rural Riverina Division of General Practice, New South Wales, Australia. Patients were identified by clinical audit, and recruited to the study if they met the inclusion criteria of being: older than 65 years, ambulant, living independently and on five or more medications. The study sample consisted of 402 participants (156 men, 38.8%; 246 women, 61.2%). Fifty-eight participants withdrew from the study for a variety of reasons. A two-group (intervention, control) pre- and post-intervention randomized study design was utilized. Quality of life was assessed using SF-36. The medication history and clinical details of the 202 study participants were reviewed by the project pharmacist and their GP. Medication changes were suggested to patients by their GP and follow-up SF36 and review of hospitalisation episodes were conducted after 6 months. RESULTS: 3382 medications were identified as being taken, an average of 8.4 medications per patient. After the initial medication review, the study pharmacist suggested an alteration in dose, form or frequency for 687 medications in the intervention group. The GPs recommended an alteration in 243 of patient medications. Of the entire study population (n = 402), only two participants' admission to hospital was specifically attributed to medication-related issues. There were no significant differences between the quality of life assessments for the combined groups; however, the intervention group recorded significantly higher scores in two of the nine dimensions measured: vitality (p 0.009) and mental health (p 0.0001), at the post-intervention assessment. CONCLUSION: While the intervention did not reduce hospitalisation episodes and only led to a modest improvement in quality of life, the development of a mutually acceptable form of face-to-face pharmacist/GP medication review, identification of potentially serious adverse drug reactions, identification of previously unreported complementary medicine use, and enhanced GP awareness of the risks of polypharmacy were positive outcomes of the study.

Journal Article↗
PubMed2005

[Guideline 'Delirium'].

The Dutch Association of Psychiatry, together with the Dutch Association of Clinical Geriatrics and with methodological support from the Dutch Institute for Healthcare Improvement (CBO) has developed a guideline for the optimal diagnosis, treatment and prevention of delirium. Delirium is caused by somatic illness or the use of medication, drugs or alcohol. Delirium is common among the somatically ill admitted to a general hospital and is associated with increased morbidity and mortality. Important predisposing factors for delirium are: age > or =70 years, cognitive disturbances, sensory impairments, problems in daily activities, and the use of alcohol and opiates. Precipitating factors that may provoke delirium are: infection, fever, dehydration, serum electrolyte imbalance, polypharmacy, and the use of psychotropic medication, particularly anticholinergic drugs. Detection, diagnosis, and assessment of the severity of delirium are based on clinical examination, case history, observation, mental status examination including tests of cognitive function, and diagnosis of underlying somatic diseases. For daily practice, measurement tools are not necessary, nor are laboratory or imaging tests, such as electroencephalography. Haloperidol is the treatment of first choice for delirium due to somatic illness, except in patients with delirium due to drug use or medication, Parkinson's disease or Lewy body dementia. In cases of concurrent alcohol withdrawal syndrome, delirium may be treated with haloperidol and a benzodiazepine and B-vitamins. Medical and environmental interventions have been shown to reduce the incidence and duration of delirium.

Aged↗
PubMed1992

Principles of drug therapy in geriatric patients.

The elderly comprise 12 percent of the U.S. population but consume 33 percent of all prescription drugs. The incidence of adverse drug reactions is significantly higher in persons over age 65 than in younger population groups. The increased risk of adverse drug effects is related to decreased organ reserve capacity, to altered pharmacokinetics and pharmacodynamics, and to polypharmacy with associated drug-drug and drug-disease interactions. An organized therapeutic plan and critical evaluation of the list of drugs an elderly patient is taking will help in establishing a safe and effective drug regimen.

Age Factors↗
PubMed2005

Chronic heart failure--optimising care in general practice.

BACKGROUND: Chronic heart failure (CHF) is a significant cause of mortality and morbidity in developed countries where it predominantly affects elderly persons with a range of other comorbid conditions requiring polypharmacy. In Australia, over 300 000 people are affected by CHF. Quality general practice forms the cornerstone for early diagnosis and evidence based integrated care. OBJECTIVE: This article examines the epidemiology of CHF, its clinical diagnosis, contemporary management and future treatment possibilities, as well as current barriers to optimal care. DISCUSSION: The global prevalence of CHF is rising. Optimal treatment requires a coordinated interdisciplinary approach using a biopsychosocial model of care in order to maximise compliance with therapy. Pharmacological treatment is essential and should include an angiotensin converting enzyme inhibitor and beta blocker where possible. Device based treatment and cardiac surgery may benefit selected cases.

Adrenergic beta-Antagonists↗
PubMed2005

Serotonin syndrome:case report and current concepts.

Selective serotonin reuptake inhibitors (SSRI's) are increasingly being used as the first line therapeutic agent for the depression. It is therefore not unusual to see a case of overdose with these agents. More commonly an adverse drug reaction may be seen among the older patients who are particularly vulnerable to the serotonin syndrome due to multiple co-morbidity and polypharmacy. The clinical picture of serotonin syndrome (SS) is non-specific and there is no confirmatory test. SS may go unrecognized because it is often mistaken for a viral illness, anxiety, neurological disorder or worsening psychiatric condition.

Adolescent↗
PubMed1992

Update on delirium.

Delirium is a common syndrome in hospitalized medical and surgical patients and in those seen in emergency departments. It is particularly common in the demented elderly patients. To prevent it, for example by avoiding polypharmacy in the elderly, is important. It is most important to diagnose delirium early and to search for its cause without delay as this may be life-saving in some patients and may help avoid injury in others. This syndrome, long neglected by investigators, calls for vigorous research to establish its epidemiology, pathogenesis, and long-term outcome.

Delirium↗
PubMed1992

Complex partial seizures. Clinical features and differential diagnosis.

Complex partial seizures are the most common seizure type in patients with partial epilepsy. Most complex partial seizures emanate from the temporal lobe; however, the seizures also may be extratemporal in origin. The clinical phenomenology may distinguish complex partial seizures from nonepileptic paroxysmal disorders and other seizure types. Physiologic and psychological disorders need to be considered in the differential diagnosis of seizure activity. Long-term EEG monitoring may be necessary for select patients to confirm the diagnosis of epilepsy and to classify appropriately seizure type. Carbamazepine and phenytoin are the antiepileptic drugs of choice in the management of complex partial seizures. Polypharmacy and use of cognitively impairing antiepileptic drugs may reduce patient compliance and further impair the quality of life of the patient with epilepsy. Finally, epilepsy surgery is an important alternative for the patient with intractable partial seizures.

Anticonvulsants↗