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Bajaj JS, Thacker LR, Heuman DM, Sterling RK, Stravitz RT, Sanyal AJ, Luketic V, Fuchs M, Gilles HCS, Wade JB. Cognitive performance as a predictor of hepatic encephalopathy in pretransplant patients with cirrhosis receiving psychoactive medications: a prospective study. Liver Transpl 2012; 18:1179-87. [PMID: 22674517 PMCID: PMC3604696 DOI: 10.1002/lt.23484] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Psychiatric disorders and medications may affect the cognitive performance of patients with cirrhosis and complicate the diagnosis and prediction of hepatic encephalopathy (HE). The aim of this study was to study the association of psychoactive medications with cognitive performance and their effects on the ability of tests to predict HE development in patients with cirrhosis referred for transplant evaluation. Cirrhosis details, psychiatric disorders, psychoactive medications, and any history of prior HE were recorded for patients with cirrhosis at 2 transplant centers. Patients were followed until the development of HE. Five cognitive tests--number connection test A (NCT-A), number connection test B, the digit symbol test (DST), the block design test, and the inhibitory control test (ICT)--were administered. A high lure score and a low ICT target score indicated poor performance. The cognitive performances of patients with psychiatric disorders/medications and patients without them were compared. A proportional hazards model was created with the time to HE as the outcome, and it was based on demographics, psychoactive medications, cirrhosis details, and individual cognitive scores. Patients with prior HE and patients without prior HE were then studied separately. One hundred fifty-five patients with a mean age of 57.5 ± 6.2 years and a mean Model for End-Stage Liver Disease (MELD) score of 15.1 ± 6.2 were included [prior HE, 48%; diabetes, 34%; selective serotonin reuptake inhibitors (SSRIs), 32%; opioids, 19%; and antipsychotics, 10%]. Prior HE and antipsychotics (but not opioids or diabetes) were associated with worse cognition. SSRI users had better NCT-A and DST performance. One hundred forty-eight patients were followed for a median of 182.5 days; 58 developed HE at a median of 99 days after inclusion. In the entire group, the model showed that prior HE (hazard ratio = 4.13), the MELD score (hazard ratio = 1.07), and a high lure score (hazard ratio = 1.04) decreased the time to HE, whereas the use of SSRIs (hazard ratio = 0.42), a high target score (hazard ratio = 0.95), and a high sodium level (hazard ratio = 0.89) increased the time to HE. For patients without prior HE, the MELD score (hazard ratio = 1.25) and lures (hazard ratio = 1.09) predicted the time to HE. Lures (hazard ratio = 1.03), targets (hazard ratio = 0.96), and sodium (hazard ratio = 0.87) were associated with the time to HE in patients with prior HE. In conclusion, cognitive tests (particularly the ICT) remain valid predictors of HE in the face of psychiatric diseases and medications. SSRI use is associated with better cognitive performance and a reduced likelihood of developing HE.
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Affiliation(s)
- Jasmohan S. Bajaj
- Division of Gastroenterology, Division of Clinical Psychology, Virginia Commonwealth University/McGuire VA Medical Center, Richmond, VA
| | - Leroy R. Thacker
- Hepatology, and Nutrition, Division of Clinical Psychology, Virginia Commonwealth University/McGuire VA Medical Center, Richmond, VA
| | - Douglas M. Heuman
- Division of Gastroenterology, Division of Clinical Psychology, Virginia Commonwealth University/McGuire VA Medical Center, Richmond, VA
| | - Richard K. Sterling
- Division of Gastroenterology, Division of Clinical Psychology, Virginia Commonwealth University/McGuire VA Medical Center, Richmond, VA
| | - R. Todd Stravitz
- Division of Gastroenterology, Division of Clinical Psychology, Virginia Commonwealth University/McGuire VA Medical Center, Richmond, VA
| | - Arun J. Sanyal
- Division of Gastroenterology, Division of Clinical Psychology, Virginia Commonwealth University/McGuire VA Medical Center, Richmond, VA
| | - Velimir Luketic
- Division of Gastroenterology, Division of Clinical Psychology, Virginia Commonwealth University/McGuire VA Medical Center, Richmond, VA
| | - Michael Fuchs
- Division of Gastroenterology, Division of Clinical Psychology, Virginia Commonwealth University/McGuire VA Medical Center, Richmond, VA
| | - Ho Chong S. Gilles
- Division of Gastroenterology, Division of Clinical Psychology, Virginia Commonwealth University/McGuire VA Medical Center, Richmond, VA
| | - James B. Wade
- Department of Biostatistics, Division of Clinical Psychology, Virginia Commonwealth University/McGuire VA Medical Center, Richmond, VA
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Abstract
Neuropsychiatric symptoms such as agitation and delusions occur commonly in elderly patients with dementia and often cause significant distress. Data on treatment efficacy are strongest for atypical antipsychotics, but these agents must be used with great caution. Adverse effects in patients with dementia include an increased risk of mortality and cerebrovascular events, as well as metabolic effects, extrapyramidal symptoms, falls, cognitive worsening, cardiac arrhythmia, and pneumonia. Conventional antipsychotics may pose an even greater safety risk. No clear efficacy evidence exists to support the use of alternative psychotropic classes (e.g., antidepressants, anticonvulsants), although they may be safer options. An antipsychotic trial is warranted when nonpharmacological intervention is unsuccessful and neuropsychiatric symptoms or associated behaviors cause severe distress or pose a significant safety risk. Before an atypical antipsychotic is started, a comprehensive assessment should be performed to rule out medical causes of the neuropsychiatric symptoms and to ascertain whether any contributing environmental or caregiver factors are present. Risks, benefits, and alternatives should be discussed with the patient and surrogate decision maker, with an opportunity given to ask questions. Dosages should be the lowest necessary, and metabolic parameters should be regularly monitored. Face-to-face visits are important to monitor response, tolerance, and the need for continued treatment. For patients in whom neuropsychiatric symptoms have been much improved or have been in remission for 3-6 months, a discontinuation trial should be considered. Through careful selection of appropriate patients for treatment, education of patients and caregivers, and close monitoring, safety risks can be minimized.
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153
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Abstract
Behavioral disturbances are frequently the most challenging manifestations of dementia and are exhibited in almost all people with dementia. Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders (insomnia, hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression). They are often persistent, greatly diminish quality of life of patients and their family caregivers, cause premature institutionalization, and pose a high economic burden on the patient, family, and society. Behavioral disturbances can be prevented and treated with a multifaceted approach that supports dignity and promotes comfort and quality of life of persons with dementia and their family members. Management involves prompt treatment of reversible factors and management of symptoms using primarily individualized nonpharmacological interventions. Pharmacological interventions need to be restricted to behavioral emergencies and for short-term treatment of behavioral disturbances that pose imminent danger to self or others.
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Affiliation(s)
- Abhilash K Desai
- Geriatric Psychiatry, Sheppard Pratt Health Systems, 6501 N Charles St, Baltimore, MD 21285, USA.
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154
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Effect of comorbidity on the risk of death associated with antipsychotic use among community-dwelling older adults. Int Psychogeriatr 2012; 24:1058-64. [PMID: 22364618 DOI: 10.1017/s1041610212000117] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antipsychotics are associated with adverse events and mortality among older adults with dementia. The objective of this study was to evaluate the risk of death associated with antipsychotic use among community-dwelling older adults with a range of comorbidities. METHODS This was a population-based cohort study of all 2,224 residents of Leppävirta, Finland, aged ≥65 years on 1 January 2000. Records of all reimbursed drug purchases were extracted from the Finnish National Prescription Register and diagnostic data were obtained from the Special Reimbursement Register. All-cause mortality was evaluated over a nine-year follow-up period. Time-dependent Cox proportional hazard models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of mortality of antipsychotic use compared to non-use. RESULTS In total, 332 residents used antipsychotics between 2000 and 2008. The unadjusted HR for risk of death associated with antipsychotic use was 2.71 (95% CI = 2.3-3.2). After adjusting for baseline age, sex, antidepressant use, and diagnostic confounders, the HR was 2.07 (95% CI = 1.73-2.47). The adjusted HR was the highest among antipsychotic users with baseline respiratory disease (HR = 2.21, 95% CI = 1.30-3.76). CONCLUSIONS The increased risk of death associated with antipsychotic use was similar across diagnostic categories, the highest being among those with baseline respiratory disease. However, the results should be interpreted with caution, as the overall sample size of antipsychotic users was small. As in other observational studies, residual confounding may account for the higher mortality observed among antipsychotic users. Further research is needed to confirm these findings.
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155
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Greenblum CA, Rowe MA. Nighttime Activity in Individuals with Dementia: Understanding the Problem and Identifying Solutions. J Gerontol Nurs 2012; 38:8-11. [DOI: 10.3928/00989134-20120410-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Puustinen J, Nurminen J, Vahlberg T, Lyles A, Isoaho R, Räihä I, Kivelä SL. CNS medications as predictors of precipitous cognitive decline in the cognitively disabled aged: a longitudinal population-based study. Dement Geriatr Cogn Dis Extra 2012; 2:57-68. [PMID: 22619661 PMCID: PMC3350354 DOI: 10.1159/000336710] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND/AIMS Psychotropics and antiepileptics (AE) are medications commonly used among the aged with cognitive decline or dementia, although they may precipitate further cognitive decline. Our aim was to analyze the relationships between the use of (i) psychotropics (i.e. benzodiazepines or related drugs, BZD, antipsychotics, AP, or antidepressants, AD), opioids (Op), anticholinergics (ACh) or AEs or the concomitant use of two of these drugs, and (ii) the risk of precipitous cognitive decline in an older (≥65 years) cognitively disabled population. METHODS A longitudinal population-based study of general aged community-dwelling patients was executed in two phases (1990-1991 and 1998-1999) in Lieto, Finland. Fifty-two individuals cognitively disabled (MMSE score 0-23) at the 1990-1991 baseline form this study's sample. Cognitive abilities were assessed in each phase with the Mini-Mental State Examination (MMSE) and medication utilization data were collected in both phases. The mean follow-up time was 7.6 years. Multivariate models were used to analyze the change in MMSE total score between medication users and non-users. RESULTS BZD or any psychotropic use was associated with greater cognitive decline in elders aged ≥75 years compared to non-users (change in MMSE sum score: -8.6 ± 7.0 vs. -3.3 ± 5.6 and -5.9 ± 7.0 vs. -2.7 ± 6.4, respectively). A greater decline was also associated specifically with the concomitant use of BZD and AP (-16 vs. -1.4 ± 7.8); as were BZD and any drug with CNS effects (-9.6 ± 9.9 vs. -1.3 ± 7.2) compared to non-users. The concomitant use of BZD and AD (-10.7 ± 4.7 vs. -3.2 ± 5.6) or ACh (-15.0 ± 8.5 vs. -3.3 ± 5.6) or any drug with CNS effects (-13.3 ± 6.5 vs. -3.3 ± 5.6) was associated with cognitive decline in patients ≥75 years compared to non-users of any drug with CNS effects. CONCLUSION The use of a BZD or any psychotropic medication may be an independent risk factor for cognitive decline in the cognitively disabled aged, and patients co-prescribed psychotropic medications had greater cognitive decline. Studies with larger sample sizes and studies on possible pathophysiologic mechanisms are needed.
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Affiliation(s)
- Juha Puustinen
- Department of Family Medicine, University of Turku, Turku and Pori, Pori
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Huybrechts KF, Schneeweiss S, Gerhard T, Olfson M, Avorn J, Levin R, Lucas JA, Crystal S. Comparative safety of antipsychotic medications in nursing home residents. J Am Geriatr Soc 2012; 60:420-9. [PMID: 22329464 PMCID: PMC3302976 DOI: 10.1111/j.1532-5415.2011.03853.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare the risk of major medical events in nursing home residents newly initiated on conventional or atypical antipsychotic medications (APMs). DESIGN Cohort study, using linked Medicaid, Medicare, Minimum Data Set, and Online Survey Certification and Reporting data. Propensity score-adjusted proportional hazards models were used to compare risks for medical events at a class and individual drug level. SETTING Nursing homes in 45 U.S. states. PARTICIPANTS Eighty-three thousand nine hundred fifty-nine Medicaid-eligible residents aged 65 and older who initiated APM treatment after nursing home admission in 2001 to 2005. MEASUREMENTS Hospitalization for myocardial infarction, cerebrovascular events, serious bacterial infections, and hip fracture within 180 days of treatment initiation. RESULTS Risks of bacterial infections (hazard ratio (HR) = 1.25, 95% confidence interval (CI) = 1.05-1.49) and possibly myocardial infarction (HR = 1.23, 95% CI = 0.81-1.86) and hip fracture (HR = 1.29, 95% CI = 0.95-1.76) were higher, and risks of cerebrovascular events (HR = 0.82, 95% CI = 0.65-1.02) were lower in participants initiating conventional APMs than in those initiating atypical APMs. Little variation existed between individual atypical APMs, except for a somewhat lower risk of cerebrovascular events with olanzapine (HR = 0.91, 95% CI = 0.81-1.02) and quetiapine (HR = 0.89, 95% CI = 0.79-1.02) and a lower risk of bacterial infections (HR = 0.83, 95% CI = 0.73-0.94) and possibly a higher risk of hip fracture (HR = 1.17, 95% CI = 0.96-1.43) with quetiapine than with risperidone. Dose-response relationships were observed for all events (HR = 1.12, 95% CI = 1.05-1.19 for high vs low dose for all events combined). CONCLUSION These associations underscore the importance of carefully selecting the specific APM and dose and monitoring their safety, especially in nursing home residents who have an array of medical illnesses and are undergoing complex medication regimens.
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Affiliation(s)
- Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02120, USA.
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Bhalerao S, Seyfried LS, Kim HM, Chiang C, Kavanagh J, Kales HC. Mortality risk with the use of atypical antipsychotics in later-life bipolar disorder. J Geriatr Psychiatry Neurol 2012; 25:29-36. [PMID: 22467844 PMCID: PMC4216676 DOI: 10.1177/0891988712436687] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION In recent years, concerns about the use of antipsychotic medications in dementia have grown. There is limited data on mortality risk of atypical antipsychotics for other psychiatric disorders of later life such as bipolar disorder. METHODS Data were derived from the national Department of Veterans Affairs registries for older patients with bipolar disorder (≥65 years) with a new start of an atypical antipsychotic (risperidone, olanzapine, or quetiapine) or valproic acid and derivatives during fiscal years 2001-2008. Six-month mortality rates were compared for individual drug groups. RESULTS The sample included 4717 patients. The risperidone cohort had the highest mortality rate (11.8 per 100 person-years) with the quetiapine and valproic acid cohorts having the lowest (5.3 and 4.6 per 100 person-years, respectively). Various methods to adjust for baseline differences including propensity models showed similar patterns. CONCLUSIONS Among older patients with bipolar disorder, there may be differences in mortality risks among individual antipsychotic agents.
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Affiliation(s)
- Sachin Bhalerao
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Lisa S. Seyfried
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Hyungjin Myra Kim
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan,Department of Veterans Affairs, Center for Clinical Management Research (CCMR), Ann Arbor, Michigan,Serious Mental Illness Treatment, Resource, and Evaluation Center (SMITREC), Ann Arbor, Michigan,Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, Michigan
| | - Claire Chiang
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan,Department of Veterans Affairs, Center for Clinical Management Research (CCMR), Ann Arbor, Michigan,Serious Mental Illness Treatment, Resource, and Evaluation Center (SMITREC), Ann Arbor, Michigan
| | - Janet Kavanagh
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Helen C. Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan,Department of Veterans Affairs, Center for Clinical Management Research (CCMR), Ann Arbor, Michigan,Serious Mental Illness Treatment, Resource, and Evaluation Center (SMITREC), Ann Arbor, Michigan
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Liang F, Terry AV, Bartlett MG. Determination of aripiprazole in rat plasma and brain using ultra-performance liquid chromatography/electrospray ionization tandem mass spectrometry. Biomed Chromatogr 2012; 26:1325-32. [DOI: 10.1002/bmc.2698] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 12/07/2011] [Accepted: 12/08/2011] [Indexed: 12/16/2022]
Affiliation(s)
- Feng Liang
- Department of Pharmaceutical and Biomedical Sciences; College of Pharmacy; The University of Georgia; Athens; GA; 30602-2352; USA
| | - Alvin V. Terry
- Department of Pharmacology and Toxicology; Georgia Health Sciences University; Augusta; GA; 30912-2300; USA
| | - Michael G. Bartlett
- Department of Pharmaceutical and Biomedical Sciences; College of Pharmacy; The University of Georgia; Athens; GA; 30602-2352; USA
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Bradas CM, Mion LC. Hospitalized Patients with Dementia: The Dilemma of Managing Agitation. Geriatr Nurs 2011; 32:455-8. [DOI: 10.1016/j.gerinurse.2011.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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161
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Ørstavik R. Antiepileptika ved Alzheimers sykdom? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011. [DOI: 10.4045/tidsskr.11.1009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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