A cohort study (with re-sampled comparator groups) to measure the association between new NSAID prescribing and upper gastrointestinal hemorrhage and perforation

This cohort study examined the relationship between newly prescribed NSAIDs (none in the previous six months) and upper gastrointestinal hemorrhage and perforation in Tayside, Scotland. Exposure was classified by prescription duration. The study population consisted of the population of Tayside. A Comparator Group was chosen at random (within age and sex strata). Two hundred re-sampled comparator groups were created. Statistical analyses were carried out by Poisson regression (repeated for each of the re-samples). The analyses controlled for age, sex, prior hospitalization for upper gastrointestinal events, prior endoscopy, and the use of ulcer healing drugs. There were 78,191 subjects in the NSAID group, and 78,207 in each of the comparator groups. The increased risk with NSAIDs was only apparent for subjects without a history of upper gastrointestinal events; univariate rate ratio = 2.76 (1.90, 4.01). The final, re-sampled estimate of NSAID risk was rate ratio = 2.48 (1.87, 3.29).

Demand for warfarin anticoagulation monitoring in Tayside, Scotland

AIM

The aim of this study was to assess the demand for warfarin prescribing and monitoring, and to identify patients with atrial fibrillation who might benefit from warfarin therapy. The study was carried out in the population of Tayside, Scotland (400,000 people) using patient-specific dispensed prescribing and hospitalisation data from the Medicines Monitoring Unit at the University of Dundee.

METHODS

The incidence and prevalence of digoxin and warfarin prescribing were calculated between 1989 and 1993. Patients dispensed digoxin in 1993 were assumed to have atrial fibrillation and they were stratified into high risk groups for an adverse thromboembolic event based on past medical history. The numbers of patients at high risk who were judged to be possible candidates for warfarin were calculated.

RESULTS

The prevalence of warfarin prescribing is increasing in Tayside and is mainly for elderly patients. There were also many patients assumed to have atrial fibrillation who were at particularly high risk for an adverse thromboembolic event, who had no record of warfarin prescribing. Only 35% received warfarin. Even given the methodological limitations of this study, and the use of aspirin as an alternative prophylactic agent, it is likely that these patients have been a source of increased prevalence of warfarin prescribing since 1993 and will be in the future. Other indications for warfarin prescribing are also increasing.

CONCLUSION

It is anticipated that there will be increasing demands for anticoagulant monitoring, which will need to be met either by increasing the capacity of existing clinics, or by increasing the role of primary care.

Room-temperature near-infrared tunable laser operation of Cr(4+):Ca(2)GeO(4)

Large crystals of highly doped Cr(4+):Ca(2)GeO(4) were grown by a top-seeded solution growth method. Absorption and emission measurements for various crystal orientations have been performed. From the spectroscopic measurements, the only optically active center was identified as tetrahedrally coordinated Cr(4+). Gainswitched, tunable laser operation of Cr(4+):Ca(2)GeO(4) crystal was demonstrated. Pulse energies of 0.4 mJ at 1.4 microm have been generated at a repetition rate of 100 Hz. Tunability over the 1348-1482-nm spectral range has been demonstrated.

Tolerability of topical NSAIDs in the elderly: do they really convey a safety advantage?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are very widely prescribed but they have a poor tolerability profile, with a range of potential adverse effects. NSAIDs that are used in topical formulations have been developed in the past 15 years and their use is increasing. The purpose is to achieve a high local concentration of the active ingredient at the affected site, with as low a plasma concentration as possible to minimise possible systemic adverse effects. The gastrointestinal and renal toxicity of topical NSAIDs has recently been highlighted in the medical literature. The elderly seem to be more sensitive to the adverse effects of NSAIDs than younger individuals, and this may also be true for topical NSAIDs. More formal epidemiological evaluation of the safety of topical NSAIDs is required in the postmarketing situation, as the main source of information regarding adverse drug reactions to topical NSAIDs in the UK has been spontaneous reporting data.

Potentially hazardous co-prescribing of beta-adrenoceptor antagonists and agonists in the community

AIM

The aim of this study was to investigate the co-prescribing of beta-antagonists and beta-agonists in the community, and to assess the potential hazards of such co-prescribing.

METHODS

The study was set in the population of Tayside, Scotland (population approximately 400,000), between January 1993 and March 1993. An automated person-specific prescribing database was used, which could also be linked to hospital admissions. Patients who were co-prescribed beta-antagonists and beta-agonists on the same day or within 30 days were selected. A model was used to identify those who showed an asthmatic profile, on the basis of age, and previous prescribing and hospitalization history, and for whom the co-prescribing was judged to be particularly hazardous.

RESULTS

Altogether, 0.9% of 15824 patients who received a beta-antagonist during the study period received a beta-agonist on the same day. This figure increased to 274 (1.7%) for 30-day co-prescription. A few instances of particularly hazardous co-prescribing were identified, which involved young people who had previously received prescriptions for corticosteroids and been hospitalized for asthma.

CONCLUSION

Potentially hazardous co-prescribing of beta-agonists and beta-antagonists occurs despite labelled warnings, even in patients who appear to be at high risk. These events are quite rare but probably should not occur at all.

Geriatric health maintenance

OBJECTIVE

To highlight articles pertaining to geriatric health maintenance and provide clinicians with current evidence supportive of or opposed to screening or treatment for various diseases and conditions.

METHOD

We conducted a computer-assisted search of the relevant medical literature and summarized the results of pertinent studies in the elderly population.

RESULTS

The geriatric population is progressively increasing in numbers. Unfortunately, no consensus exists about health maintenance in this population. To date, the United States Preventive Services Task Force has made several recommendations about preventive services; however, they did not specifically focus on the geriatric age-group. We outline their guidelines and discuss our clinical practices in a wide variety of encounters with geriatric patients.

CONCLUSION

The efficacy of many screening tests and interventions for preventing illness in elderly patients is unclear. As the general population continues to age, further research in this area will be important.

Constipation in an elderly community: a study of prevalence and potential risk factors

OBJECTIVE

The epidemiology of chronic constipation in the elderly remains poorly defined. We aimed to study the prevalence of, and potential risk factors for, constipation in a representative elderly community, using symptom-based diagnostic criteria.

METHODS

An age and gender-stratified random sample of 1833 eligible residents of Olmsted County, Minnesota, aged 65 yr and over, was mailed a valid self-report questionnaire; 1375 responded (75%).

RESULTS

The overall age- and gender-adjusted prevalence (per 100) of any constipation was 40.1 (95% CI 38.9, 44.4); for functional constipation and outlet difficulty or delay, the prevalence rates were 24.4 (95% CI 22.0-26.9) and 20.5 (95% CI 18.2-22.8), respectively. Self-reported constipation did not reliably identify functional constipation or outlet delay. Outlet delay, but not functional constipation, was more frequent in women; functional constipation, but not outlet delay, was associated with advancing age. Nonsteroidal anti-inflammatory drugs and other medications were significant risk factors in subjects with functional constipation and outlet delay combined.

CONCLUSIONS

In independently living, elderly persons, constipation is a common complaint; among these subjects, there appear to be symptom subgroups that can be identified.

Constipation and fecal incontinence in the elderly population

OBJECTIVE

To describe the assessment and management of constipation and fecal incontinence in elderly patients.

DESIGN

We reviewed pertinent publications in the recent medical literature and outlined effective management strategies for constipation and fecal incontinence in the geriatric population.

RESULTS

Constipation can be classified into two syndromes--functional constipation and rectosigmoid outlet delay. Evaluation consists of elicitation of a detailed history, directed physical examination, and selected laboratory tests. Management involves nonpharmacologic (such as exercise and fiber) and pharmacologic measures. Fecal incontinence in elderly patients can be due to stool impaction, medications, dementia, or neuromuscular dysfunction. Management options include modification of contributing disorders, pharmacologic therapy, and behavioral techniques.

CONCLUSION

Constipation and fecal incontinence are common and often debilitating conditions in elderly patients. Management should be highly individualized and dependent on cause, coexisting morbidities, and cognitive status.

Urinary incontinence in the elderly population

OBJECTIVE

To describe the causes, evaluation, and management of urinary incontinence in the elderly population.

DESIGN

We reviewed pertinent articles in the medical literature and summarized the types of incontinence and contributing factors.

RESULTS

Urinary incontinence is common in elderly patients and often has a major role in determining whether a person can remain independent in the community or requires nursing home placement. Urinary incontinence is not a single entity but rather several different conditions, each with specific symptoms, findings on examination, and recommended treatment. Thus, accurate classification is important for appropriate management. Because of the complexity of urinary incontinence, many physicians are uncomfortable with undertaking assessment and treatment. Hence, many patients are not asked about incontinence, and the condition remains untreated and often considered a natural consequence of the aging process. Urinary incontinence can be treated and either cured or alleviated with treatment.

CONCLUSION

Elderly patients should be asked about symptoms of urinary incontinence because appropriate assessment and treatment can usually provide relief.

Common rheumatologic diseases in elderly patients

OBJECTIVE

To review common rheumatologic disorders that affect elderly patients and emphasize the unique diagnostic and therapeutic challenges inherent in the management of rheumatologic diseases in this age-group.

DESIGN

We summarize our approach to treatment and management of specific rheumatologic problems in geriatric patients and discuss pertinent studies from the literature.

RESULTS

Among the spectrum of rheumatologic disorders frequently encountered in the elderly population are polymyalgia rheumatica, fibromyalgia, giant cell arteritis, crystalline arthropathies (gout and pseudogout), and degenerative joint disease. The initial manifestations of these rheumatologic diseases in elderly patients may differ from the typical findings in younger patients. Geriatric patients may have nonspecific complaints, a decline in physical function, or even confusion. Because of physiologic changes associated with aging and a decrease in functional reserves, elderly patients are susceptible to adverse effects of pharmacologic therapy (including nonsteroidal anti-inflammatory medications, corticosteroids, narcotic analgesics, allopurinol, and colchicine). Clinicians should be alert for such problems as hepatotoxicity and occult gastrointestinal blood loss. Comorbid conditions such as cardiovascular disease and cognitive impairment may complicate management strategies and may limit the goals of both surgical intervention and rehabilitation programs in elderly patients.

CONCLUSION

Rheumatologic disorders in geriatric patients pose special challenges to primary-care physicians. In the selection of optimal pharmacologic and nonpharmacologic therapeutic modalities, clinicians should focus on maintaining or improving the patient's quality of life and level of independent function.

Rehabilitation of geriatric patients

OBJECTIVE

To describe the role of geriatric rehabilitation, the methods of practice, and the mechanisms underlying integrated care in rehabilitation medicine.

DESIGN

We reviewed the rehabilitation-related medical literature and outlined an approach to the evaluation of impairment in older patients and subsequent rehabilitation planning.

RESULTS

For optimal rehabilitation of geriatric patients, knowledge of general principles of rehabilitation and key areas affecting the elderly population is important. A rehabilitation program will be most successful if a team approach--including a physician, rehabilitation nurse, physical therapist, occupational therapist, psychologist, medical social worker, and recreational therapist--is used. Attention should be paid to special considerations in older patients (such as the presence of comorbid conditions) and potential barriers to care in order to maximize benefit.

CONCLUSION

Rehabilitation of elderly patients can assist in preserving functional independence and improving the quality of life. Assessment and management in an individual patient are best performed by a team approach.

Pharmacologic therapies in dementia

OBJECTIVE

To review past and current pharmacologic therapies for cognitive and behavioral problems in elderly patients with dementia.

DESIGN

We surveyed the pertinent medical literature and present detailed findings on results of pharmacotherapeutic interventions for cognitive loss and behavioral disorders.

RESULTS

Numerous drugs have been used in an attempt to reverse or forestall the cognitive decline associated with dementia. Currently available agents are limited by either lack of efficacy or occurrence of adverse effects. Medications are also used to control undesirable behaviors associated with dementia. Depending on the individual circumstance, such pharmacologic therapies may be of limited utility, some may be harmful, and others may be effective. The use of psychotropic agents in nursing homes is strictly regulated by federal law. For appropriate care of elderly patients with dementia, knowledge of the available drug therapies and their effectiveness is necessary.

CONCLUSION

Drug therapies for dementia are associated with adverse effects in the elderly population. Drugs for management of aggressive behaviors associated with dementia should be used only when nondrug strategies have failed. In each patient with dementia, underlying cognitive and behavioral problems must be thoroughly evaluated for selection of the most appropriate drug.

Management of dementia-related behavioral disturbances: a nonpharmacologic approach

OBJECTIVE

To describe practical nonpharmacologic approaches to dementia-related behavioral problems for enhancement of the function and care of elderly patients with dementia.

DESIGN

We reviewed the pertinent medical literature and summarized strategies and available resources for management of geriatric patients with dementia and behavior problems.

RESULTS

For optimal care of older patients with dementia, key concepts of related behavior problems must be understood. Agitation and aggression, resisting help with care, wandering, incontinence, sleep disturbance, and emotional lability can become difficult management issues with such patients. In some patients, these disruptions can lead to overmedication and nursing home placement. Herein, practical nonpharmacologic measures for management of behavior problems that arise among community-dwelling and institutionalized elderly patients with dementia are discussed. Attention is directed to the medical, psychologic, environmental, and social factors that may contribute to unwanted behaviors.

CONCLUSION

Nonpharmacologic approaches can help ameliorate behavioral problems and assist in the overall care of elderly patients with dementia.

Venous obstruction due to a distended urinary bladder

Bladder distention is an infrequently reported cause of venous obstruction that may be confused clinically with deep venous thrombosis or congestive heart failure. Urinary symptoms may be minimal or absent. Herein we describe a 73-year-old man with unilateral lower extremity edema caused by a distended urinary bladder. In addition, we review the clinical manifestations of 15 previously reported cases of venous obstruction due to urinary retention. Of the 15 patients, all but 1 had painless bilateral lower extremity edema. In most cases, the cause of bladder distention was benign prostatic enlargement.

Recognition and management of anxiety and depression in elderly patients

OBJECTIVE

To describe important aspects of the recognition and management of anxiety and depression in elderly patients.

DESIGN

We reviewed pertinent recent articles in the medical literature and compiled guidelines for diagnosing and treating anxiety and depression in the geriatric population.

RESULTS

Depression and anxiety are common in the elderly population. The development of depression in elderly subjects is associated with a higher risk of death from suicide than for any other age-group. Recognition of depression in elderly patients is often hampered by an inability or reluctance on the part of these patients to report depressive symptoms. In addition, anxiety and depression are often attributed to organic illness in this age-group. Pharmacotherapy is effective; however, older patients are probably more likely than young patients to experience adverse effects. Using medications at lower doses, choosing drugs with shorter half-lives, and avoiding drugs with potent anticholinergic side effects are often advisable.

CONCLUSION

Anxiety and depression are common conditions among the elderly population. Correct recognition, attention to underlying precipitating factors, and compassionate, supportive care can vastly improve the quality of the lives of these patients.

Delirium in elderly patients: evaluation and management

OBJECTIVE

To review the evaluation and management of delirium in elderly patients for primary-care providers.

DESIGN

We summarize the clinical features, course, pathophysiologic aspects, predisposing factors, causes, and differential diagnosis of delirium and discuss approaches to affected patients and various management strategies.

RESULTS

Delirium, an altered mental state, occurs more frequently in elderly than in younger patients. The pathophysiologic changes associated with aging and the higher occurrence of multiple medical problems and need for medications contribute to the higher frequency of delirium in elderly patients. Evaluation should begin with a consideration of the most common causes, such as a change in or addition to prescribed medications, a withdrawal from alcohol or other sedative-hypnotic drugs, an infection, or a sudden change in neurologic, cardiac, pulmonary, or metabolic state. Finally, management of delirium is threefold: (1) identifying and treating underlying causes, (2) nonpharmacologic interventions, and (3) pharmacologic therapies to manage symptoms of delirium.

CONCLUSION

Elderly patients frequently experience delirium. Delirious symptoms can produce devastating consequences if they are not recognized and appropriately treated.

Comparison of heart rate and arterial pressure spectra during head up tilt and a matched level of LBNP

Lower Body Negative Pressure (LBNP) can be used to stimulate cardiovascular regulation by inducing blood shifts similar to those produced during head up tilt (HUT). It is unclear, however, whether similar blood shifts produced by these two stresses evoke similar cardiovascular regulatory responses. Hence, we compared the autonomic components of cardiovascular responses to 50 degrees HUT and a matched level of LBNP. A level of LBNP that produced changes in calf circumference similar to those produced during the first 3 min of 50 degrees HUT was considered to be a matched level. Autonomic components of cardiovascular responses were determined by spectral analysis of heart rate and blood pressure. Results from nine subjects showed that in terms of changes in calf circumference at the end of 3 min, 50 degrees HUT and 48 mm Hg LBNP were similar (2.13% and 1.94%). During 20-min exposures to HUT and LBNP, the increase in heart rate during LBNP was greater (+7 bpm) than HUT, while blood pressure increases were similar. For heart rate and blood pressure spectra, power in the respiratory frequency region (0.25 Hz) decreased and power in the low frequency region (0.03 Hz) increased similarly during HUT and LBNP. These results indicated that 50 degrees HUT and a matched level of LBNP evoked similar autonomic responses in cardiovascular regulation, with the autonomic balance shifted toward increased sympathetic and decreased parasympathetic influence.

Override of spontaneous respiratory pattern generator reduces cardiovascular parasympathetic influence

We investigated the effects of voluntary control of breathing on autonomic function in cardiovascular regulation. Variability in heart rate was compared between 5 min of spontaneous and controlled breathing. During controlled breathing, for 5 min, subjects voluntarily reproduced their own spontaneous breathing pattern (both rate and volume on a breath-by-breath basis). With the use of this experimental design, we could unmask the effects of voluntary override of the spontaneous respiratory pattern generator on autonomic function in cardiovascular regulation without the confounding effects of altered respiratory pattern. Results from 10 subjects showed that during voluntary control of breathing, mean values of heart rate and blood pressure increased, whereas fractal and spectral powers in heart rate in the respiratory frequency region decreased. End-tidal PCO2 was similar during spontaneous and controlled breathing. These results indicate that the act of voluntary control of breathing decreases the influence of the vagal component, which is the principal parasympathetic influence in cardiovascular regulation.

An audit of the accuracy of upper gastrointestinal diagnoses in Scottish Morbidity Record 1 data in Tayside

INTRODUCTION

Scottish Morbidity Record (SMR1) data are coded by trained clerical staff from case records and discharge summaries. They form the basis of many strategic NHS decisions. Their accuracy for upper gastrointestinal (UGI) diagnosis is unknown and the study was undertaken to assess this accuracy in Tayside.

METHOD

Patients who fulfilled the following criteria were identified using a record-linkage pharmacoepidemiological database, and their case records retrieved: over 50 years of age, had encashed at least one prescription for a non-steroidal anti-inflammatory drug at a Tayside pharmacy and who had SMR1 records containing one or more symptom/diagnosis codes between January 1989 and December 1991. Medically qualified staff were trained to examine case records and to code UGI diagnoses. They searched the case records for every UGI SMR1 entry for these patients from 1980-1992 and produced re-coded diagnoses (RCD) for each hospital event (admission and discharge), using all the data available in the case records. They also abstracted data on the clinical presentation, investigations and management of patients. Each event was then examined by a single medically qualified researcher who compared the original SMR1 codes with the RCDs.

RESULTS

2,101 patients had a total of 3,764 events in 1989-1991. 317 events were either day case procedures or elective surgery or the case records were not found. They were therefore excluded. Of the remainder, the SMR1 and RCD codes were judged equivalent in 1,608 events (46.6%). However, 1,005 SMR1 events (29.2%) contained a symptom code but no diagnosis code and the remaining 834 (24.2%) were judged suboptimal for other reasons. Of those with a symptom code only, 406 could not be improved upon and were transformed into RCD symptom codes only, 435 were assigned symptom and diagnostic RCDs and 164 were assigned diagnostic RCDs only. In the other 834 events, 279 had one or more diagnoses missing, 425 had one or more diagnoses inaccurate, 23 had both missing and inaccurate diagnoses and 107 were not UGI. Thus 1,433 (41.6%) of UGI SMR1 events could be more accurately coded. Examination of investigation data revealed that coding inaccuracy was not due to diagnostic procedures being carried out after admission.

CONCLUSION

UGI SMR1 data were satisfactory in about half of all events. In about a quarter there were symptom codes but no satisfactory diagnosis codes, whilst in another quarter the data were inaccurate. These findings have implications for health care activities and research that use these data.

Practical functional assessment of elderly persons: a primary-care approach

OBJECTIVE

To describe simple, practical measures of physical and psychosocial function to detect problems and enhance the care of elderly patients.

DESIGN

We reviewed pertinent articles and current standard textbooks of geriatrics; the most useful findings are summarized, and tools that can be used for functional assessment of the geriatric population are presented.

RESULTS

Care of elderly patients necessitates a comprehensive review of key areas of function. Using only clinical judgment, physicians may overlook important clinical deficits common in older patients. Because of their length and complexity, many of the standard geriatric assessment tools are impractical for use by primary-care physicians. Certain simplified or condensed versions--such as the Functional Reach Test and the "Get Up and Go" Test--are efficient substitutes. In this article, we describe methods for practical identification of functional impairments, assessment of cognition and mood, evaluation of hearing and vision, and detection of problems with continence, nutrition, and social needs. Instruments for assessment of caregiver burden are also outlined.

CONCLUSION

Use of the assessment tools presented herein can assist primary-care physicians in comprehensive evaluation of function in older patients.

Pressure ulcers: prevention and management

OBJECTIVE

To describe important aspects of pressure ulcer prevention and management, especially in elderly patients.

DESIGN

We reviewed pertinent published material in the medical literature and summarized effective strategies in the overall management of the elderly population with pressure ulcers.

RESULTS

Pressure ulcers are commonly encountered in geriatric patients. The development of a pressure ulcer is associated with an increased risk of death. Certain well-recognized risk factors, such as immobility and incontinence, may predispose to the development of pressure ulcers; consequently, risk factor modification is an important aspect of prevention and treatment. For existing lesions, various innovative patient support surfaces and wound care products have been developed to alleviate pressure and to facilitate wound healing. The use of a particular product should be based on the clinical setting and the limited scientific evidence available. With treatment, most pressure ulcers eventually heal.

CONCLUSION

Pressure ulcers are often, but not always, preventable. The occurrence of such an ulcer signals the possible presence of chronic comorbid disease and should prompt a search for underlying risk factors in patients for whom ulcer treatment is considered appropriate.

Non-steroidal anti-inflammatory drugs and hospitalization for acute renal failure

Non-steroidal anti-inflammatory drugs (NSAIDs) have been implicated in the aetiology of acute renal failure (ARF), but epidemiological studies examining this association have produced disparate results. We conducted a case-control study using a purpose-built record-linkage database for a population of 420,600 patients, resident in Tayside since May 1990. Patients (n = 207) hospitalized with a diagnostic code for ARF between 1990 and 1992 had their diagnosis validated by a renal physician. Six community controls and two hospital controls, matched for age and sex, were generated for each of these cases. Exposure to dispensed oral NSAIDs, topical NSAIDs and aspirin during the 90 days prior to the index date were investigated (recent exposure), as was exposure at any time since January 1989 (previous exposure). The most significant associations were modelled using conditional logistic regression. When community controls were used, recent exposure to NSAIDs and previous exposure to aspirin were independently associated with hospitalization for ARF, with adjusted odds ratios of 2.20 (1.49-3.25) and 2.19 (1.46-3.30), respectively. Only recent exposure to oral NSAIDs was associated when hospital controls were used: 1.84 (1.14-2.93). No significant interactions were present with previous chronic renal failure, other possible causes of ARF or whether the diagnosis was primary or secondary. There is an approximate doubling of the risk of hospitalization for ARF with use of oral NSAIDs.