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PubMed2005

Prevalence of malnutrition and risk factors in geriatric patients of a convalescent and rehabilitation hospital.

OBJECTIVES: To investigate the prevalence and risk factors of malnutrition in geriatric patients admitted to a convalescent and rehabilitation hospital. DESIGN: Cross-sectional study. SETTING: Regional hospital, Hong Kong. PATIENTS: A total of 120 patients (aged 60 years or older) referred to Tung Wah Eastern Hospital. MAIN OUTCOME MEASURES: Anthropometric, biochemical, and haematological parameters were measured for nutritional assessment. Malnutrition was defined as a body mass index of lower than 18.5 kg/m(2) and serum albumin level of lower than 35 g/L. The clinical outcomes of patients were also recorded. The predictive value of the Chinese Mini Nutritional Assessment as a nutritional screening tool was assessed. Potential risk factors associated with malnutrition were evaluated according to established protocols. RESULTS: The mean age of patients was 80.3 years (standard deviation, 7.4 years), and the mean body mass index was 21.9 kg/m(2) (standard deviation, 4.4 kg/m(2)). The prevalence of malnutrition was 16.7%. The age distribution of malnourished patients (mean, 86.2 years; standard deviation, 7.0 years; n=20) was significantly different to those nourished (mean, 79.1 years; standard deviation, 6.9 years; n=100) [P=0.0001]. Mortality was also higher in malnourished patients (25%) than nourished patients (4%) [P=0.001]. Based on the Chinese Mini Nutritional Assessment, 16.9% of patients were classified as malnourished (cut-off value, 18.5). The Chinese Mini Nutritional Assessment was useful as a screening tool to exclude patients who were not malnourished, ie it had a high negative predictive value (95%). Being totally dependent for the performance of activities of daily living, living in a home for the elderly, and being chair- or bed-bound posed a significantly increased risk of malnutrition. The presence of mental depression (geriatric depression scale score of 8 or higher), moderately or severely impaired cognitive function (abbreviated mental test score of lower than 7), or polypharmacy (five medications or more) did not significantly affect risk of malnutrition. CONCLUSIONS: Malnutrition was common in the geriatric patients studied and was associated with an increased mortality. The Chinese Mini Nutritional Assessment was a useful screening tool to exclude malnutrition. Significant risk factors of malnutrition were total dependence, living in a home for the elderly, and being chair- or bed-bound.

Age Factors↗
PubMed2004

Aging and cancer.

A substantial increase in the number of elderly people in the populations of developed nations in the coming years has been projected. Persons 65 years and older are at significantly higher risk of developing cancer when compared to younger individuals. There is a resulting increase in cancer incidence as well as mortality in this advanced age group. It is important to know how changes in physiological reserve and functional status in elderly patients, polypharmacy issues, comorbidities, and other age-related problems can affect cancer prognosis and management. Elderly patients are not adequately represented in clinical trials, thus creating a relative lack of information related to specific issues about elderly cancer patients and their care. Nevertheless, there is a substantial amount of guidance available, and in this review we will address selected issues of importance when considering the approach to the older cancer patient.

Activities of Daily Living↗
PubMed2005

[Statins--"21st century aspirin"?].

Doctors prescribe patients more and more medications. This predominantly affects elderly people. Polypharmacy is more and more frequent and predominantly affects elderly people. It may lead to many harmful and virtually life threatening drug interactions. There is pressing need to investigate new remedies, which would be applied in many different and coexisting medical conditions. It is vital particularly in case of elderly people who usually suffer from many different diseases which have numerous common pathogenetic pathways. 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, also known as statins, are a widely prescribed drug class for treatment of dyslipidemias and their complications such as coronary artery disease, stroke and peripheral arteriosclerosis. Now, there is accumulating evidence that statins also have beneficial pleiotropic effects that may make them useful in treatment of such diseases as dementia, osteoporosis, some forms of cancer, diabetes mellitus and its microangiopathic complications, hypertension and prevent deep vein thrombosis. Should we call statins "21st century aspirin?" This paper reviews recent data concerning the possibility of using statins in new indications; particularly in dementia (including Alzheimer's disease), osteoporosis, cardiovascular accidents and some forms of neoplasms.

Dementia↗
PubMedDate not supplied

Palonosetron improves prevention of chemotherapy-induced nausea and vomiting in elderly patients.

Although elderly patients have been reported to be less prone to chemotherapy-induced nausea and vomiting (CINV), its management is complicated by a high frequency of comorbidities and polypharmacy and an increased risk of dehydration and impaired cognition. The comparative efficacy and tolerability of palonosetron and ondansetron/dolasetron were assessed in a retrospective post hoc analysis using pooled data from 171 elderly patients (age > or = 65 years) with cancer enrolled in two randomized, double-blind, phase III clinical studies comparing single IV doses of these antiemetic agents given prior to receipt of moderately emetogenic chemotherapy. The complete response rate during the postchemotherapy period was significantly higher in the palonosetron group than in the ondansetron/dolasetron group in the 5 days following chemotherapy. The proportion of patients who were nausea-free on the problematic days 2 and 3 post chemotherapy and the time to treatment failure also significantly favored palonosetron. In this population that included patients with pre-existing comorbidities, palonosetron was well tolerated, with similar or fewer adverse events than the comparators. Comparisons in electrocardiogram parameters revealed that the mean postdose change from baseline in QTc interval was 3 ms for palonosetron 0.25 mg and 5 ms for ondansetron/dolasetron. In this retrospective analysis, palonosetron provided superior efficacy to ondansetron/dolasetron for the treatment of CINV in elderly patients receiving moderately emetogenic chemotherapy. Based on its safety profile, antiemetic control, and convenient dosing, palonosetron can be recommended for use in elderly patients with cancer receiving emetogenic chemotherapy.

Aged↗
PubMed2005

Diagnosis, treatment, and management of irritable bowel syndrome with constipation and chronic constipation.

Irritable bowel syndrome with constipation (IBS-C) and chronic constipation are 2 common gastrointestinal motility disorders that place a substantial burden on patients and society. Symptoms of both disorders are chronic, sometimes severe, and often respond poorly to treatment with traditional approaches, resulting in reduced quality of life, polypharmacy, and frequent healthcare utilization. Because structural, physical, or biochemical markers cannot be used to identify either disorder, diagnosis is symptom-based. In the absence of alarm features suggestive of organic disease or secondary causes of symptoms, these disorders can be positively and confidently diagnosed. In general, traditional agents used to treat patients with constipation target only a single symptom, and do not provide adequate relief of symptoms in the majority of IBS-C patients. Although patients with mild constipation symptoms may respond to treatment with fiber and laxatives, others with moderate-to-severe symptoms may require additional therapies and/or referral to a specialist for further evaluation. The advent of novel serotonergic agents has rejuvenated the therapeutic approach to patients with IBS-C and chronic constipation.

Chronic Disease↗
PubMedDate not supplied

[Epilepsy in the elderly].

INTRODUCTION: Epilepsy is a frequent pathology in the elderly, but its aetiology, clinical presentation and prognosis are different to those seen in younger patients. DEVELOPMENT: Beyond a certain age physiological modifications take place in the metabolism that alter the pharmacokinetics of the antiepileptic drugs (AED) and increase the risk of pharmacological interactions, which is already higher in these patients owing to the frequency of polypharmacy. Moreover, elderly patients are especially sensitive to certain side effects of AED, such as cognitive disorders, osteoporosis or weight increase. Since the efficacy of the more important AED is a priori quite similar and the epilepsies we have to deal with at this age usually have a good prognosis, the choice of AED will depend more on their pharmacokinetics and their potential to trigger certain side effects than on their effectiveness. CONCLUSIONS: The ones with the most favourable pharmacokinetic profile are levetiracetam and pregabalin, followed oxcarbazepine and lamotrigine. Additionally, these drugs generally have few cognitive effects, do not give rise to osteoporosis and, with the exception of pregabalin, do not alter the patient's weight, all of which makes them first choice drugs for the treatment of epilepsy in the elderly.

Adult↗
PubMedDate not supplied

Medication knowledge and self-management by people with type 2 diabetes.

OBJECTIVE: To explore medication knowledge and self-management practices of people with type 2 diabetes. DESIGN: A one-shot cross sectional study using in-depth interviews and participant observation. SETTING: Diabetes outpatient education centre of a university teaching hospital. SUBJECTS: People with type 2 diabetes, n=30, 17 males and 13 females, age range 33-84, from a range of ethnic groups. OUTCOME MEASURES: Ability to state name, main actions and when to take medicines. Performance of specific medication-related tasks; opening bottles and packs, breaking tablets in half, administering insulin, and testing blood glucose. RESULTS: Average medication use > or = 10years. Respondents were taking 86 different medicines, mean 7 +/- 2.97 SD. Dose frequency included two, three and four times per day. All respondents had > or = 2 diabetic complications +/- other comorbidities. The majority (93%) were informed about how and when to take their medicines, but only 37% were given information about side effects and 17% were given all possible seven items of information. Younger respondents received more information than older respondents. Older respondents had difficulty opening bottles and breaking tablets in half. Twenty percent regularly forgot to take their medicines. Increasing medication costs was one reason for stopping medicines or reducing the dose or dose interval. The majority tested their blood glucose but did not control test their meters and 33% placed used sharps directly into the rubbish. CONCLUSION: Polypharmacy was common. Medication knowledge and self-management were inadequate and could lead to adverse events.

Adult↗
PubMed2006

[Cardiological (pharmaco)therapy and dental practice].

In recent years much progress has been made in the treatment of acute coronary syndromes, heart failure and cardiac rhythm disturbances. Polypharmacy including two antiplatelet drugs (aspirin and clopidogrel) is common in many patients after a percutaneous coronary intervention using a 'stent'. Discontinuation of these drugs for invasive dental treatment may result in coronary rethrombosis. However, in many patients with coronary artery disease, a temporal pause in the use of aspirin appears safe and may decrease the risk of bleeding after a dental procedure. An increasing number of patients with heart failure and/or life threatening rhythm disturbances receive an implantable cardioverter defibrillator (ICD). Such a device, equipped with a left ventricular lead, also stimulates the left ventricle in case of delayed electrical conduction (e.g. a left bundle branch block). This so called cardiac resynchronization therapy decreases morbidity and mortality in selected patients. ICDs are safe in the dental office even in case of discharge. In patients with prosthetic heart valves, endocarditis prophylaxis according to the current guidelines is recommended before invasive dental treatment. Dentists are advised to contact the Dutch Thrombosis Service to discuss the dose of oral ancicoagulants and the required INR value. In case of urgent and/or extended dental procedures, admittence to a hospital must be considered to secure optimal therapy.

Aspirin↗
PubMed1991

[Clinical evaluation of intra-arterial infusion of hyperthermo-chemotherapy in gastric cancer].

We performed intra-arterial infusion hyperthermochemotherapy by retaining an intra-arterial reservoir in 17 lesions of 12 patients with non-resectable, metastatic or recurrent gastric cancers. The 12 patients consisted of one with a primary gastric cancer lesion, 6 with a solitary gastric cancer lesion metastasizing to the liver, 4 with gastric cancer accompanied by hepatic metastasis, lymph node metastasis or local recurrence, and one with a gastric cancer lesion metastasizing to Douglas' pouch. A catheter was retained in the hepatic artery of all 6 patients with a solitary gastric cancer lesion metastasizing to the liver, and a catheter was retained in the aorta of the patient with a primary lesion, 3 of the 4 patients with two or more metastatic lesions, and the patient with a lesion metastasizing to Douglas' pouch. The duration of each hyperthermia session was 50 minutes, and one or two sessions were performed within a week. One course consisting of 5 or 6 sessions was repeated. Antineoplastic drugs such as MMC, 5-FU, ADR, epi-ADR, CDDP and VP-16 were injected in bolus form or administered serially through the reservoir. Nine of the 12 patients had polypharmacy. One to 3 courses or 4 to 20 sessions at maximum (average 9.8 sessions) were given. The rate of efficacy of intra-arterial infusion hyperthermochemotherapy was 44% for hepatic metastasis and 25% for lymph node metastasis. The local recurrent lesions, the lesion metastasizing to Douglas' pouch and the primary lesion did not respond to therapy.

Adenocarcinoma, Mucinous↗
PubMed2006

Interactions between general and regional anesthesia.

Neuraxial blockade is commonly used to abolish sensations elicited by noxious stimuli during surgical procedures. Proven advantages of combined anesthesia include early recovery from general anesthesia and postoperative analgesia, together with likely decreases in blood loss, cardiac dysrhythmias, or ischemic events and postoperative deep vein thrombosis. The side effects of the technique are related to the dose or site of local anesthetic administration and to light general anesthesia, which can result in awareness during surgery. Varying degrees of synergistic interactions have been reported among the drugs used to achieve the anesthetic state. Spinal anaesthesia appears to have sedative effects, and local anesthetics used for neuraxial blockade have been found to reduce the induction and maintenance dosage of midazolam, thiopental, propofol and inhaled anesthetics. The growing interest in combining local and general anesthesia has led to studies investigating possible interactions between general anesthesia and local anesthetics administered via spinal or epidural routes. Neuraxial blockade reduces sedative and anesthetic requirements by decreasing ascending sensory input into the brain. This has important clinical implications, as anesthetists should expect to reduce anesthetic and sedative drug doses during neuraxial blockade, unless the blockade involves lower dermatomes alone. Clinical practice of anesthesia is a polypharmacy, wherein the anesthetic state is the net result of the action of different drugs and their interaction in the presence of a surgical stimulus.

Anesthetics, General↗
PubMed2006

[Risk of overtreatment: not to be neglected. The example of antiepileptic drugs].

Overtreatment (unnecessary treatment, excessive drug dosages, unjustified polypharmacy) alters the risk-benefit ratio. Its prevention requires the recognition of the situations and the understanding of the mechanisms leading to it. The pharmacological treatment of epilepsy exposes to such a risk and serves as an example for its detection and correction.

Anticonvulsants↗
PubMedDate not supplied

[Drug interactions: from theory to practice].

Pharmacotherapy becomes increasingly complex and therapeutic targets are more and more ambitious for both care and prevention. Therefore, polypharmacy is frequent, which exposes the patient to a high risk of drug-drug interactions. These are often underestimated although they are responsible for many adverse events that may be serious and even fatal. In the present paper, we will first briefly recall the main cautions in the use of medications as well as the most common conditions favouring the occurrence of harmful drug interactions. Then, we will analyze the various mechanisms leading to drug interactions, emphasizing especially those involving cytochrome P450 enzymatic system and P-glycoprotein. Finally, we will illustrate these theoretical considerations with some examples of drug interactions, among the most dangerous and the most frequent in clinical practice.

Cytochrome P-450 Enzyme System↗
PubMed2006

[Psychobiological significance of antipsychotics in multi-high dose drug therapy for schizophrenia].

In this session, the development of antipsychotics and 'atypicality' were discussed firstly. Various concepts regarding 'atypicality' had the meaning of optimal modulation of dopamine. Then, the key role of dopamine for psychotic symptoms and the question how antipsychotics should work for managing those symptoms were treated by introducing the theories by Kapur and Yagi. And from all these reasons, it came to the conclusion that megadose-polypharmacy treatment should be avoided.

Antipsychotic Agents↗
PubMed2006

[Theory in antipsychotic drug therapy for schizophrenia].

In Japan, antipsychotic polypharmacy with high doses for schizophrenia has been traditionally used. However, antipsychotic polyphamacy with high doses provide disadvantages for patient. Recent PET studies show that dopamine D2 occupancy with antipsychotics is important for the treatment of schizophrenia. First, antipsychotics become effective only at which their D2 occupancy exceeds 65%. Second, antipsychotics with D2 occupancy below 90% rarely causes occupancy exceeds 65%. Second, antipsychotics with D2 occupancy below 90% rarely causes extrapyramidal side effect. These results suggest that monopharmacy which uses a single antipsychotic agent with appropriate dose is recommended for schizophrenia treatment.

Antipsychotic Agents↗
PubMed2006

[The syndrome of inappropriate antidiuretic hormone secretion (SIADH) during treatment with the antipsychotic agents haloperidol and quetiapine].

A 45-year-old man with paranoid schizophrenia repeatedly developed hyponatraemia due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), both after treatment with haloperidol and after taking quetiapine. This side effect did not occur subsequently during clozapine treatment. SIADH has been described in connection with almost all psychotropic drugs. Since the risk of developing SIADH is increased with increasing age, comorbid somatic disorders and polypharmacy, and the mean age of the psychiatric patient will further increase in the years to come, the physician should be alert to the risk factors and the clinical symptoms of disturbances in water balance; moreover, the proper differential diagnostic deliberations should be made. In case of increased risk, it is recommended to monitor the serum sodium during the first 2-4 weeks of pharmacotherapy.

Age Factors↗
PubMed2005

[History of opium poppy and morphine].

Opium has been known for millennia to relieve pain and its use for surgical analgesia has been recorded for several centuries. The Sumerian clay tablet (about 2100 BC) is considered to be the world's oldest recorded list of medical prescriptions. It is believed by some scholars that the opium poppy is referred to on the tablet. Some objects from the ancient Greek Minoan culture may also suggest the knowledge of the poppy. A goddess from about 1500 BC shows her hair adorned probably with poppy-capsules and her closed eyes disclose sedation. Also juglets probably imitating the poppy-capsules were found in that period in both Cyprus and Egypt. The first authentic reference to the milky juice of the poppy we find by Theophrastus at the beginning of the third century BC. In the first century the opium poppy and opium was known by Dioscorides, Pliny and Celsus and later on by Galen. Celsus suggests the use of opium before surgery and Dioscorides recommended patients should take mandrake (contains scopolamine and atropine) mixed with wine, before limb amputation. The Arabic physicians used opium very extensively and about 1000 AD it was recommended by Avicenna especially in diarrhoea and diseases of the eye. Polypharmacy, including a mixture of nonsensical medications were often used. Fortunately for both patients and physicians many of the preparations contained opium. The goal was a panacea for all diseases. A famous and expensive panacea was theriaca containing up to sixty drugs including opium. Simplified preparations of opium such as tinctura opii were used up to about 2000 in Denmark. In the early 1800s sciences developed and Sertürner isolated morphine from opium and was the founder of alkaloid research. A more safe and standardized effect was obtained by the pure opium. Several morphine-like drugs have been synthesized to minimize adverse effects and abuse potential. Opioid receptors were identified and characterized in binding assays and their localization examined. However, the complexity of the system including interaction with several neurons and transmitters indicate the goal of nonaddictive opiates to be elusive. Combination therapy, innovative delivery systems and long-acting formulations may improve clinical utility.

Ancient Lands↗
PubMed2007

Rhinitis in the elderly.

Very little has been published regarding rhinitis in the elderly. Changes in the nose due to aging include structural, hormonal, mucosal, olfactory, and neural effects. The effects of polypharmacy may contribute to causing congestion and dryness. Physicians should look for treatable causes of rhinitis such as allergic rhinitis or rhinosinusitis, and rule out neurodegenerative disorders if applicable. Treatments that may provide symptomatic relief include humidification and antiallergy therapies. Surgery for structural and skin conditions of the external nose may also provide relief in some cases. As the U.S. population ages and remains in overall better health, we may learn more about the effects of aging on rhinitis.

Aged↗
PubMed2006

Management issues in the metabolic syndrome.

The metabolic syndrome or cardiovascular dysmetabolic syndrome is characterized by obesity, central obesity, insulin resistance, atherogenic dyslipidemia, and hypertension. The major risk factors leading to this syndrome are physical inactivity and an atherogenic diet and cornerstone clinical feature is abdominal obesity or adiposity. In addition, patients usually have elevated triglycerides, low HDL cholesterol, elevated LDL cholesterol, other abnormal lipid parameters, hypertension, and elevated fasting blood glucose. Impaired fibrinolysis, increased susceptibility to thrombotic events, and raised inflammatory markers are also observed. Given that India has the largest number of subjects with type-2 diabetes in the world it can be extrapolated that this country also has the largest number of patients with the metabolic syndrome. Epidemiological studies confirm a high prevalence. Therapeutic approach involves intervention at a macro-level and control of multiple risk factors using therapeutic lifestyle approaches (diet control and increased physical activity, pharmacotherapy - anti-obesity agents) for control of obesity and visceral obesity, and targeted approach for control of individual risk factors. Pharmacological therapy is a critical step in the management of patients with metabolic syndrome when lifestyle modifications fail to achieve the therapeutic goals. Anti-obesity drugs such as sibutramine and orlistat can be tried to reduce weight and central obesity and jointly control the metabolic syndrome components. Other than weight loss, there is no single best therapy and treatment should consist of treatment of individual components of the metabolic syndrome. Newer drugs such as the endocannabinoid receptor blocker,rimonabant, appear promising in this regard. Atherogenic dyslipidemia should be controlled initially with statins if there is an increase in LDL cholesterol. If there are other lipid abnormalities then combination therapy of statin with fibrates, nicotinic acid, or ezetimibe should be considered. For insulin resistance, drugs such as thiazolidinediones and renin-angiotensin system blockers are available. Available evidence suggests that angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBS) may be more beneficial for treatment of hypertension in patients with metabolic syndrome compared to others as these drugs also prevent development of diabetes. Patients with metabolic syndrome also have elevations in fibrinogen and other coagulation factors leading to prothrombotic state and aspirin may be beneficial for primary prevention in these patients. The new developments in the treatment of metabolic syndrome with drugs, such as peroxisome proliferator-activated receptor (PPAR) agonists and cannabinoid receptor-1 antagonists, will broaden the horizons of the current treatment options. Fixed-dose combination polypharmacy using a single pill is an interesting concept that needs to be evaluated in long-term prospective trials in such patients.

Diet↗