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Houix M, Humbert I, D'Acremont F, Sauvaget A, Huon JF, Bulteau S. What about the relevance of PIP of psychotropics in older psychiatric inpatients? L'ENCEPHALE 2024:S0013-7006(24)00114-3. [PMID: 38981810 DOI: 10.1016/j.encep.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/15/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE In 2019, a regional survey of potentially inappropriate prescriptions (PIP) of psychotropic drugs in elderly psychiatric inpatients was carried out highlighting their inappropriate use in this population. The aim of this study was to assess the clinical relevance - defined as the provision of an appropriate and necessary treatment, chosen from other alternatives as being the most likely to produce the expected results for a given patient - of these prescriptions considered inappropriate according to current established criteria. MATERIAL AND METHOD Patients aged over 75, or 64 to 75 and polypathological with at least one PIP of psychotropic drugs or drugs with a high anticholinergic burden, identified by an audit grid established on the basis of STOPP/STARTv2 criteria and the Laroche list on the prescription at 48h of hospitalization, were included. The weighing of the inappropriateness nature of the prescription (resistance to treatment, period of crisis, comorbidities…) was established by a pharmacist-psychiatrist pair on the entire computerized record of the current episode. The clinical relevance of the PIP and the overall prescription was rated as 0 (irrelevant), 1 (partially relevant) or 2 (relevant). RESULTS Thirty-four patients were included. One hundred and twenty-five PIP of psychotropic drugs were noted: 50.4% concerned benzodiazepines and non-benzodiazepines anxiolytics (BZD/Z), 25.6% neuroleptics (NL), 12% antidepressants (ATD) and 12% drugs with a high anticholinergic burden. On one hand, 49.2% of PIP of BZD/Z, 50% of PIP of NL and 20% of PIP of ATD were considered irrelevant. On the other hand, 49.2% of PIP of BZD/Z, 31.3% of PIP of NL and 13.3% of PIP of ATD were considered partially relevant. Furthermore, 1.6% of PIP of BZD/Z, 18.8% of PIP of NL and 66.7% of PIP of ATD were considered relevant. For PIPs of drugs with a high anticholinergic burden, 80% were deemed irrelevant, 13.3% partially relevant and 6.7% relevant. In all, of the 34 drug prescriptions studied, three (8.8%) were considered irrelevant, 11 (32.4%) partially relevant and 20 (58.8%) clinically relevant. CONCLUSION This study highlighted the clinical relevance of more than half the prescriptions considered inappropriate according to current PPI criteria in the elderly. It underlines the interest of a new PPI detection tool for elderly patients with psychiatric disorders.
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Affiliation(s)
- Morgane Houix
- Service pharmacie, centre hospitalier universitaire de Nantes, 44000 Nantes, France.
| | - Ilia Humbert
- Unité PPANs, centre hospitalier universitaire de Strasbourg, 67091 Strasbourg, France
| | - Fanny D'Acremont
- Service pharmacie, centre hospitalier universitaire de Nantes, 44000 Nantes, France; OMEDIT Pays de la Loire, 44000 Nantes, France
| | - Anne Sauvaget
- Département de psychiatrie et addictologie, centre hospitalier universitaire de Nantes, 44000 Nantes, France
| | - Jean-François Huon
- Service pharmacie, centre hospitalier universitaire de Nantes, 44000 Nantes, France
| | - Samuel Bulteau
- Département de psychiatrie et addictologie, centre hospitalier universitaire de Nantes, 44000 Nantes, France
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Ye C, Shen J, Zhang C, Hu C. Impact of intraoperative dexmedetomidine on postoperative delirium and pro-inflammatory cytokine levels in elderly patients undergoing thoracolumbar compression fracture surgery: A prospective, randomized, placebo-controlled clinical trial. Medicine (Baltimore) 2024; 103:e37931. [PMID: 38701286 PMCID: PMC11062712 DOI: 10.1097/md.0000000000037931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/28/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND This study evaluates the efficacy of dexmedetomidine (DEX) in reducing postoperative delirium (POD) and modulating pro-inflammatory cytokines in elderly patients undergoing thoracolumbar compression fracture surgery. METHODS In this randomized, double-blind, placebo-controlled trial conducted from October 2022 to January 2023 at Anting Hospital in Shanghai, 218 elderly patients were randomized into DEX (n = 110) and normal saline (NS, n = 108) groups. The DEX group received 0.5 µg/kg/h DEX, and delirium incidence was assessed using the Confusion Assessment Method (CAM) on days 1 to 3 post-surgery. Levels of interleukins IL-1β, IL-6, and tumor necrosis factor-α (TNF-α) were measured pre-operation (T0) and on postoperative days 1 (T1) and 3 (T3). Preoperative (T0) and postoperative day 1 (T1) cerebrospinal fluid (CSF) samples were treated with varying concentrations of olanzapine or DEX to observe their regulatory effects on the expression of Phospho-ERK1/2 and Phospho-JNK. RESULTS Dexmedetomidine significantly lowered the incidence of POD to 18.2%, compared to 30.6% in the NS group (P = .033). While all patients showed an initial increase in cytokine levels after surgery, by T3, IL-6 and TNF-α levels notably decreased in the DEX group, with no significant change in IL-1β levels across groups. The adverse events rate was similar between groups, demonstrating the safety of DEX in this population. In postoperative CSF samples, treatment with 0.5 mM DEX significantly downregulated Phospho-JNK and upregulated Phospho-ERK1/2 expression, demonstrating a dose-dependent modulation of inflammatory responses. CONCLUSION Dexmedetomidine is effective in reducing early POD in elderly patients post-thoracolumbar compression fracture surgery. It also decreases IL-6 and TNF-α levels, indicating its potential in managing postoperative inflammatory responses. Treatment with 0.5 mM DEX significantly modulated Phospho-ERK1/2 and Phospho-JNK expressions in postoperative CSF samples, indicating a dose-dependent effect on reducing inflammation. This study contributes to understanding DEX's role in improving postoperative outcomes in elderly patients.
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Affiliation(s)
- Caimin Ye
- Department of Anesthesiology, Shanghai Jiading District Anting Hospital, Shanghai, China
| | - Jian Shen
- Department of Anesthesiology, Shanghai Jiading District Anting Hospital, Shanghai, China
| | - Chengcheng Zhang
- Department of anesthesiology, Chang-Hai Hospital, The Second Military Medical University, Shanghai, China
| | - Cuiyun Hu
- Department of Anesthesiology, Shanghai Jiading District Anting Hospital, Shanghai, China
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Fischer CE, Namasivayam A, Crawford-Holland L, Hakobyan N, Schweizer TA, Munoz DG, Pollock BG. Psychotic Disorders in the Elderly: Diagnosis, Epidemiology, and Treatment. Psychiatr Clin North Am 2022; 45:691-705. [PMID: 36396273 DOI: 10.1016/j.psc.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This review covers the latest advances in our understanding of psychosis in the elderly population with respect to diagnosis, epidemiology, and treatment. Major topics of discussion include late life psychiatric disorders such as schizophrenia, schizoaffective disorder, and delusional disorder as well as dementia-related psychosis. Clinical differences between early-onset and late-onset disorders are reviewed in terms of prevalence, symptomatology, and approach to treatment. Newly revised research and clinical criteria for dementia-related psychosis are referenced. The evidence base for emerging therapies including citalopram and pimavanserin in relation to conventional therapies such as atypical antipsychotics are discussed..
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Affiliation(s)
- Corinne E Fischer
- Keenan Research Centre for Biomedical Science, Room 17044 cc wing, St. Michaels Hospital, #30 Bond St., Toronto, Ontario, M5B1W8, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
| | - Andrew Namasivayam
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Lucas Crawford-Holland
- Keenan Research Centre for Biomedical Science, Room 17044 cc wing, St. Michaels Hospital, #30 Bond St., Toronto, Ontario, M5B1W8, Canada
| | - Narek Hakobyan
- Keenan Research Centre for Biomedical Science, Room 17044 cc wing, St. Michaels Hospital, #30 Bond St., Toronto, Ontario, M5B1W8, Canada
| | - Tom A Schweizer
- Keenan Research Centre for Biomedical Science, Room 17044 cc wing, St. Michaels Hospital, #30 Bond St., Toronto, Ontario, M5B1W8, Canada; St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Department of Neurosurgery, University of Toronto, Toronto, Canada
| | - David G Munoz
- Keenan Research Centre for Biomedical Science, Room 17044 cc wing, St. Michaels Hospital, #30 Bond St., Toronto, Ontario, M5B1W8, Canada; St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Bruce G Pollock
- Division of Geriatric Psychiatry, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario, M5T 1R8, Canada; Toronto Dementia Research Alliance, University of Toronto, Toronto, Ontario, Canada
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The Interplay between Anticholinergic Burden and Anemia in Relation to 1-Year Mortality among Older Patients Discharged from Acute Care Hospitals. J Clin Med 2021; 10:jcm10204650. [PMID: 34682773 PMCID: PMC8539729 DOI: 10.3390/jcm10204650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/26/2021] [Accepted: 10/08/2021] [Indexed: 01/15/2023] Open
Abstract
Anticholinergic burden (ACB) and anemia were found associated with an increased risk of death among older patients. Additionally, anticholinergic medications may contribute to the development of anemia. Therefore, we aimed at investigating the prognostic interplay of ACB and anemia among older patients discharged from hospital. Our series consisted of 783 patients enrolled in a multicenter observational study. The outcome of the study was 1 year mortality. ACB was assessed by an Anticholinergic Cognitive Burden score. Anemia was defined as hemoglobin < 13 g/dL in men and <12 g/dL in women. The association between study variables and mortality was investigated by Cox regression analysis. After adjusting for several potential confounders, ACB score = 2 or more was significantly associated with the outcome in anemic patients (HR = 1.93, 95%CI = 1.13–3.40), but not non anemic patients (HR = 1.51, 95%CI = 0.65–3.48). An additive prognostic interaction between ACB and anemia was observed (p = 0.02). Anemia may represent a relevant effect modifier in the association between ACB and mortality.
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Vickers LE, Martinez AI, Wallem AM, Johnson C, Moga DC. Potentially Inappropriate Medication Use in Older Adults with Alzheimer's Disease and Related Dementias Living in the Community: A Cross-Sectional Analysis. Drugs Real World Outcomes 2021; 8:519-526. [PMID: 34114133 PMCID: PMC8605947 DOI: 10.1007/s40801-021-00265-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND With the older adult population in the USA increasing, so is the population of those with Alzheimer's disease and related dementias (ADRD). Older adults are vulnerable to the effects of potentially inappropriate medications as established by the Beers Criteria; however, some medications continue to be prescribed against recommendations. OBJECTIVES Our objectives were to describe potentially inappropriate medication (PIM) use linked to cognitive impairment or decline (referred to as Cog-PIM) in older adults with and without ADRD and to investigate whether the odds of Cog-PIM report differ by ADRD status in ambulatory care (i.e., outpatient care) in the USA. METHODS A cross-sectional analysis was performed using a nationally representative sample of non-perioperative, office-based ambulatory care visits by adults aged ≥ 65 years in 2016 (n = 218,182,131). Data were collected from the National Ambulatory Medical Care Survey. Cog-PIMs were identified as defined in the 2015 Beers Criteria recommendations for medications that may be potentially inappropriate in older adults with cognitive impairment or dementia. ADRD status was determined by clinician report using free text, the ADRD flag, or the presence of a diagnosis code indicating dementia. Multivariable logistic regressions were used to estimate the odds of Cog-PIM use overall and by medication class. RESULTS In 2016, 2.1% (n = 4,651,563) of outpatient visits were made by older adults with ADRD, 33.2% of which reported at least one Cog-PIM. Anticholinergic Cog-PIMs were noted in 20.5% of ADRD visits compared with 8.1% of non-ADRD visits. Antipsychotic PIMs were noted in 15.5% of ADRD visits compared with 0.8% of non-ADRD visits. Benzodiazepine and non-benzodiazepine receptor agonist hypnotic (Z drug) Cog-PIMs were reported in 10.9% of ADRD visits and 10.7% of non-ADRD visits. ADRD status was a significant predictor of Cog-PIM report overall (adjusted odds ratio [aOR] 2.74 [95% confidence interval {CI} 1.20-6.27]) and for anticholinergics and antipsychotics specifically (aOR 3.35 [95% CI 1.24-9.03] and aOR 22.80 [95% CI 5.80-89.50], respectively). CONCLUSION This study demonstrated a high prevalence of Cog-PIM use and increased odds of Cog-PIM use in older adults with ADRD. Future work should investigate opportunities in the ambulatory care setting for safer prescribing and de-escalation of Cog-PIMs.
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Affiliation(s)
| | | | | | - Clare Johnson
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Daniela C Moga
- University of Kentucky College of Pharmacy, Lexington, KY, USA. .,University of Kentucky College of Public Health, Lexington, KY, USA. .,University of Kentucky Institute for Pharmaceutical Outcomes and Policy, Lexington, KY, USA. .,Sanders-Brown Center on Aging, Lexington, KY, USA.
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Toto S, Hefner G, Hahn M, Hiemke C, Roll SC, Wolff J, Klimke A. Current use of anticholinergic medications in a large naturalistic sample of psychiatric patients. J Neural Transm (Vienna) 2021; 128:263-272. [PMID: 33439364 DOI: 10.1007/s00702-020-02298-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/27/2020] [Indexed: 12/19/2022]
Abstract
Due to the high number of psychotropic drugs with anticholinergic potential, patients taking psychotropic drugs are at high risk for anticholinergic adverse drug reactions (ADRs). The aim of this study was to analyze the prevalence and type of pharmacodynamic anticholinergic drug-drug interactions in psychiatric patients. The retrospective longitudinal analysis used data from a large pharmacovigilance study conducted in ten German psychiatric hospitals. Anticholinergic burden of drugs was defined as "strong" or "moderate" based on current literature. Number and type of anticholinergic drugs were assessed. In total, 27,396 patient cases (45.6% female) with a mean age of 47.3 ± 18.3 years were included. 17.4% (n = 4760) of patients were ≥ 64 years. 35.4% of the patients received between one and four anticholinergic drugs simultaneously. A combination of drugs with anticholinergic potential was detected in 1738 cases (6.3%). Most prescribed drugs were promethazine (n = 2996), olanzapine (n = 2561), biperiden (n = 1074), and doxepin (n = 963). Patients receiving anticholinergic combinations were younger (45.7 vs. 47.4 years, p < 0.01) and had a longer inpatient stay (median 18 vs. 26.5 days, p < 0.001). The prevalence of anticholinergic drug use in psychiatry is high. Further efforts need to focus on reducing the rate of anticholinergics and inappropriate medication especially in the elderly. Anticholinergic ADRs can be prevented by avoiding high-risk drug combinations. Replacing tricyclic antidepressants and first-generation antihistamines with drugs with lower anticholinergic potential and avoiding biperiden could reduce 59.3% of anticholinergic drug application.
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Affiliation(s)
- Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany.
| | - Gudrun Hefner
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany
| | - Martina Hahn
- Psychiatric Hospital, Vitos Klinik Eichberg, Eltville, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center of Mainz, Mainz, Germany
| | - Sibylle C Roll
- Psychiatric Hospital, Vitos Klinik Eichberg, Eltville, Germany
| | - Jan Wolff
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Evangelical Foundation Neuerkerode, Braunschweig, Germany
| | - Ansgar Klimke
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany.,Heinrich-Heine-University, Duesseldorf, Germany
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7
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Potentially inappropriate medication in older psychiatric patients. Eur J Clin Pharmacol 2020; 77:331-339. [PMID: 33029652 DOI: 10.1007/s00228-020-03012-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/01/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Many psychotropic drugs are listed as potentially inappropriate medication (PIM) in the older population. Potentially inappropriate means that prescription of those drugs in older adults may cause significant harm. The objective of this study was to analyze the prevalence and sort of PIM prescribing in a naturalistic, real-world psychiatric setting. METHODS The retrospective analysis gathered data from a large pharmacovigilance study, conducted at 10 psychiatric hospitals. Data from inpatients aged ≥ 65 years were included for the analysis. The number and sort of PIM, as defined by the German PRISCUS list, were controlled by analyzing the patients' medication profile. RESULTS In total, 4760 patient cases (59.2% female) with a mean (mean ± standard deviation (SD)) age of 77.33 ± 7.77 years were included into the study. Altogether, 1615 cases (33.9%) received at least 1 PRISCUS-PIM per day (regular and as-needed medication included). The most frequently prescribed PRISCUS-PIM (n = 2144) were zopiclone > 3.75 mg/day (n = 310), lorazepam > 2 mg/day (n = 269), haloperidol > 2 mg/day (n = 252), and diazepam (n = 182). Cases with PRISCUS-PIM were younger (75.7 vs. 78.2 years, p < 0.001) and had a longer (26 vs. 22 days, p < 0.001) hospital length of stay. Replacing benzodiazepines and z-substances, haloperidol > 2 mg, tricyclic antidepressants, first generation antihistaminergic drugs, and clonidine by non-PIM could reduce 69.9% of PRISCUS-PIM-prescribing. CONCLUSIONS The prevalence of PRISCUS-PIM is high in the hospitalized psychiatric setting. Rational deprescribing of inappropriate anticholinergics, benzodiazepines, and antipsychotics in the older population is a key component to reduce the risk of adverse drug reactions. More tolerable medications should be prescribed.
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Ozzoude M, Nakajima S, Plitman E, Chung JK, Kim J, Iwata Y, Caravaggio F, Takeuchi H, Uchida H, Graff-Guerrero A, Gerretsen P. The effects of illness severity, cognition, and estimated antipsychotic dopamine receptor occupancy on insight into the illness in schizophrenia: An analysis of clinical antipsychotic trials of intervention effectiveness (CATIE) data. Prog Neuropsychopharmacol Biol Psychiatry 2019; 89:207-213. [PMID: 30172739 DOI: 10.1016/j.pnpbp.2018.08.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 08/19/2018] [Accepted: 08/29/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND The relationship between dopamine D2 receptor (D2R) occupancy and impaired illness awareness (IIA) remains unclear. While IIA is associated with illness severity and cognitive dysfunction, antipsychotic medication, the principal treatment for schizophrenia, indirectly improves IIA, but may simultaneously contribute to cognitive dysfunction at supratherapeutic doses. AIM AND METHODS We investigated the influence of estimated D2R (Est.D2R) occupancy by antipsychotics on the relationships between IIA and illness severity, and IIA and cognition. IIA was assessed in 373 adult patients with schizophrenia (18-62 years) using data from CATIE. IIA was measured using the Positive and Negative Syndrome Scale (PANSS) item G12. D2R occupancy levels were estimated from plasma concentrations for risperidone, olanzapine, and ziprasidone. Correlation, regression, and path analyses were performed to examine IIA's relationship to illness severity, cognition, and Est.D2R. RESULTS Illness severity was predictive of IIA. However, premorbid IQ, cognition, and Est.D2R did not predict IIA, and Est.D2R did not serve either a moderating or mediating role in both regression and path analyses. CONCLUSIONS Consistent with previous literature, our results suggest that IIA is a function of illness severity in adult patients with schizophrenia. Future studies should explore whether D2R occupancy mediates the relationships between IIA and illness severity, and IIA and cognitive dysfunction, in late-life schizophrenia (i.e. ≥60 years) given the effects of aging on cognition, IIA, and antipsychotic sensitivity.
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Affiliation(s)
- Miracle Ozzoude
- University of Toronto, Toronto, Ontario, Canada; Multimodal Imaging Group, Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Eric Plitman
- Multimodal Imaging Group, Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Jun Ku Chung
- Multimodal Imaging Group, Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Julia Kim
- Multimodal Imaging Group, Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Yusuke Iwata
- Multimodal Imaging Group, Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Fernando Caravaggio
- Multimodal Imaging Group, Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Schizophrenia Division, Complex Mental Illness Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Geriatric Mental Health Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Ariel Graff-Guerrero
- Multimodal Imaging Group, Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Ontario, Canada; Geriatric Mental Health Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Philip Gerretsen
- Multimodal Imaging Group, Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Ontario, Canada; Geriatric Mental Health Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Ontario, Canada.
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Corsonello A, Cozza A, D'Alia S, Onder G, Volpato S, Ruggiero C, Cherubini A, Di Rosa M, Fabbietti P, Lattanzio F. The excess mortality risk associated with anticholinergic burden among older patients discharged from acute care hospital with depressive symptoms. Eur J Intern Med 2019; 61:69-74. [PMID: 30449478 DOI: 10.1016/j.ejim.2018.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/03/2018] [Accepted: 11/10/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The relationship between anticholinergic burden and mortality is controversial, and the impact of anticholinergic burden on prognosis may vary in presence of other conditions common in old age. We aimed at investigating the role of depressive symptoms as potential effect modifiers in the association between anticholinergic burden and 1-year mortality in older patients discharged from hospital. METHODS Our series consisted of 576 older patients consecutively admitted to seven geriatric and internal medicine acute care wards in the context of a prospective multicenter observational study. Overall anticholinergic burden was assessed by Anticholinergic Cognitive Burden (ACB) score. Depressive symptoms were assessed by 15-item Geriatric Depression Scale (GDS). The study outcome was all-cause mortality during 12-months follow-up. Statistical analysis was carried out by Cox regression analysis. RESULTS After adjusting for potential confounders, discharge ACB score = 2 or more was significantly associated with the outcome among patients with GDS > 5 (HR = 3.70; 95%CI = 1.18-11.6), but not among those with GDS ≤ 5 (HR = 2.32; 95%CI = 0.90-6.24). The association was confirmed among depressed patients after adjusting for ACB score at 3-month follow-up (HR = 3.58; 95%CI = 1.21-10.7), as well as when considering ACB score as a continuous variable (HR = 1.42; 95%CI = 1.10-1.91). The interaction between ACB score at discharge and BADL dependency was statistically significant (p < .005). CONCLUSIONS ACB score at discharge may predict mortality among older patients discharged from acute care hospital carrying high GDS score e. Hospital physician should be aware that prescribing anticholinergic medications in such a vulnerable population may have negative prognostic implications.
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Affiliation(s)
- Andrea Corsonello
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona and Cosenza, Italy.
| | - Annalisa Cozza
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona and Cosenza, Italy
| | - Sonia D'Alia
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona and Cosenza, Italy
| | - Graziano Onder
- Department of Gerontology, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Gemelli University Hospital, Rome, Italy
| | - Stefano Volpato
- Department of Medical Sciences, Section of Internal and Cardiorespiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Carmelinda Ruggiero
- Section of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di Ricerca per l'Invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Mirko Di Rosa
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona and Cosenza, Italy
| | - Paolo Fabbietti
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona and Cosenza, Italy
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Trenaman SC, Hill-Taylor BJ, Matheson KJ, Gardner DM, Sketris IS. Antipsychotic Drug Dispensations in Older Adults, Including Continuation After a Fall-Related Hospitalization: Identifying Adherence to Screening Tool of Older Persons' Potentially Inappropriate Prescriptions Criteria Using the Nova Scotia Seniors' Pharmacare Program and Canadian Institute for Health's Discharge Databases. Curr Ther Res Clin Exp 2018; 89:27-36. [PMID: 30294400 PMCID: PMC6170214 DOI: 10.1016/j.curtheres.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 12/25/2022] Open
Abstract
Purpose Despite well-established concerns regarding adverse drug effects, antipsychotics are frequently prescribed for older adults. Our first objective was to identify trends in antipsychotic dispensations to older Nova Scotians. STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) criteria identify antipsychotic use in those with a history of falls as potentially inappropriate. Our second objective was to identify trends, predictors, and adherence with this STOPP criteria by identifying continued antipsychotic dispensations following a fall-related hospitalization. Methods A descriptive cross-sectional cohort study of Nova Scotia Seniors’ Pharmacare Program (NSSPP) beneficiaries ≥ 66 years with at least one antipsychotic dispensation annually from April 1, 2009 to March 31, 2014 was completed. As well, unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 were linked to fall-related hospitalizations recorded in the Canadian Institute for Health Information Discharge Abstract Database. The relationship of age, sex, fiscal year, days supply and length-of-stay were studied to identify predictors of continued antipsychotic dispensation post-discharge. Descriptive statistics and multivariate logistic analysis were performed. Odds ratios for the association of risk factors and adherence to STOPP criteria were calculated. Findings We identified that in each year observed, there were 6% of eligible NSSPP beneficiaries that received at least one antipsychotic dispensation. Approximately 70% of antipsychotic dispensations were for second generation agents, primarily quetiapine and risperidone. Of the unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 who survived a fall-related hospitalization over 75% were dispensed an antipsychotic in the 100 days following hospital discharge. Logistic regression showed no statistically significant association between potentially inappropriate therapy and potential predictors in multivariate analysis. Implications In each year from 2009 to 2014, 6% of Nova Scotia Seniors’ Pharmacare beneficiaries were dispensed at least one antipsychotic prescription. Over 75% of the older adults who received an antipsychotic dispensation in the 100 days prior to a fall-related hospitalization, continued the drug class after discharge. This demonstrates that despite the recommendations of quality indicators such as the STOPP criteria, antipsychotics are continued in individuals at a high risk of falling. Future investigations are needed to inform health team, system, and policy interventions to improve concordance with this antipsychotic specific STOPP criterion when appropriate.
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Affiliation(s)
- Shanna C Trenaman
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.,Geriatric Medicine Research Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | | | - Kara J Matheson
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - David M Gardner
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ingrid S Sketris
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
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11
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Lattanzio F, Onder G, La Fauci MM, Volpato S, Cherubini A, Fabbietti P, Ruggiero C, Garasto S, Cozza A, Crescibene L, Tarsitano A, Corsonello A. Anticholinergic Burden is Associated With Increased Mortality in Older Patients With Dependency Discharged From Hospital. J Am Med Dir Assoc 2018; 19:942-947. [PMID: 30049542 DOI: 10.1016/j.jamda.2018.06.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/06/2018] [Accepted: 06/11/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To determine whether anticholinergic burden may predict differently 1-year mortality in older patients discharged from acute care hospitals with or without dependency in basic activities of daily living (BADL). DESIGN Prospective observational study. SETTING AND PARTICIPANTS Our series consisted of 807 patients aged 65 years or older consecutively discharged from 7 acute care geriatric wards throughout Italy between June 2010 and May 2011. MEASURES Overall anticholinergic burden was assessed by the anticholinergic cognitive burden (ACB) score. Dependency was rated by BADL, and dependency in at least 1 BADL was considered as a potential mediator in the analysis. The study outcome was all-cause mortality during 12-months of follow-up. RESULTS Patients included in the study were aged 81.0 ± 7.4 years, and 438 (54.3%) were female. During the follow-up period, 177 out of 807 participants (21.9%) died. After adjusting for potential confounders, discharge ACB score = 2 or more was significantly associated with the outcome among patients with dependency in at least 1 BADL [hazard ratio (HR) 2.25 95% confidence (CI) 1.22‒4.14], but not among independent ones (HR 1.06 95% CI 0.50‒2.34). The association was confirmed among dependent patients after adjusting for the number of lost BADL at discharge (HR 2.20 95% CI 1.18‒4.04) or ACB score at 3-month follow-up (HR 2.18 95% CI 1.20‒3.98), as well as when considering ACB score as a continuous variable (HR 1.28 95% CI 1.11‒1.49). The interaction between ACB score at discharge and BADL dependency was highly significant (P < .001). CONCLUSIONS/IMPLICATIONS ACB score at discharge may predict mortality among older patients discharged from an acute care hospital carrying at least 1 BADL dependency. Hospital physicians should be aware that prescribing anticholinergic medications in this population may have negative prognostic implications and they should try to reduce anticholinergic burden at discharge whenever possible.
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Affiliation(s)
- Fabrizia Lattanzio
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Graziano Onder
- Department of Gerontology, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Gemelli University Hospital, Rome, Italy
| | | | - Stefano Volpato
- Department of Medical Sciences, Section of Internal and Cardiorespiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Antonio Cherubini
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Paolo Fabbietti
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Carmelinda Ruggiero
- Section of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy
| | - Sabrina Garasto
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Annalisa Cozza
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Lucia Crescibene
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Assunta Tarsitano
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Andrea Corsonello
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy.
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12
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McClarty BM, Fisher DW, Dong H. Epigenetic Alterations Impact on Antipsychotic Treatment in Elderly Patients. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2018; 5:17-29. [PMID: 29755923 PMCID: PMC5943049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE OF THE REVIEW Antipsychotics are commonly prescribed for the treatment of psychosis as well as behavioral and psychological symptoms of dementia (BPSD) in elderly patients. However, elderly patients often experience decreased antipsychotic efficacy and increased side effects, though the mechanisms underlying these changes with age are not clear. RECENT FINDINGS Although aging can affect drug metabolism and clearance through changes in renal and hepatic function, additional pharmacokinetic and pharmacodynamic changes due to aging-induced epigenetic alterations also impact processes important for antipsychotic function. Epigenetic mechanisms account for some of the altered efficacy and increased side effects seen in elderly patients. SUMMARY Both clinical and animal studies from our group and others have demonstrated a plausible epigenetic mechanism involving histone modifications that can adversely affect the efficacy of antipsychotics and increase their side effects in elderly patients. Hopefully, further investigation of this mechanism will benefit elderly patients who need treatment for psychosis and BPSD.
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Affiliation(s)
- Bryan M. McClarty
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Daniel W. Fisher
- Department of Neurology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Hongxin Dong
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
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13
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Changes in medicine prescription following a medication review in older high-risk patients with polypharmacy. Int J Clin Pharm 2018; 40:480-487. [PMID: 29453677 PMCID: PMC5918522 DOI: 10.1007/s11096-018-0602-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 02/01/2018] [Indexed: 12/02/2022]
Abstract
Background The more (inappropriate) drugs a patient uses, the higher the risk of drug related problems. To reduce these risks, medication reviews can be performed. Objective To report changes in the prescribed number of (potentially inappropriate) drugs before and after performing a medication review in high-risk polypharmacy patients. A secondary objective was to study reasons for continuing potentially inappropriate drugs (PIDs). Setting Dutch community pharmacy and general medical practice. Methods A retrospective longitudinal intervention study with a pre-test/post-test design and follow-up of 1 week and 3 months was performed. The study population consisted of 126 patients with polypharmacy and with additional risk for drug related problems that underwent a medication review in five community pharmacies. The medication review was performed by the pharmacist in close cooperation with the general practitioner of each corresponding patient. Main outcome measure Number of (potentially inappropriate) drugs, and appropriateness of prescribed medicines. Results The average number of drugs a patient used 1 day before the review was 8.7 (SD = 2.9), which decreased (p < 0.05) to 8.3 (SD = 2.7) 1 week after the review, and to 8.4 (SD = 2.6) 3 months after the review. The average number of PIDs was initially 0.6 (SD = 0.8) per patient and decreased to 0.4 (SD = 0.6, p < 0.05). Twenty-two of the 241 initial drug changes (9%) were deprescribed during follow-up. Registered reasons for continuing PIDs are clinical or patients’ preferences. Conclusions Performing medication reviews in polypharmacy patients seems useful to continue at least in high-risk patients in The Netherlands. The time-consuming reviews could be limited to patients who are willing to change their medication.
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14
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Montalvo-Ortiz JL, Fisher DW, Rodriguez G, Fang D, Csernansky JG, Dong H. Histone deacetylase inhibitors reverse age-related increases in side effects of haloperidol in mice. Psychopharmacology (Berl) 2017; 234:2385-2398. [PMID: 28421257 PMCID: PMC5538925 DOI: 10.1007/s00213-017-4629-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 04/04/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Older patients can be especially susceptible to antipsychotic-induced side effects, and the pharmacodynamic mechanism underlying this phenomenon remains unclear. We hypothesized that age-related epigenetic alterations lead to decreased expression and functionality of the dopamine D2 receptor (D2R), contributing to this susceptibility. METHODS In this study, we treated young (2-3 months old) and aged (22-24 months old) C57BL/6 mice with the D2R antagonist haloperidol (HAL) once a day for 14 days to evaluate HAL-induced motor side effects. In addition, we pretreated separate groups of young and aged mice with histone deacetylase (HDAC) inhibitors valproic acid (VPA) or entinostat (MS-275) and then administered HAL. RESULTS Our results show that the motor side effects of HAL are exaggerated in aged mice as compared to young mice and that HDAC inhibitors are able to reverse the severity of these deficits. HAL-induced motor deficits in aged mice are associated with an age- and drug-dependent decrease in striatal D2R protein levels and functionality. Further, histone acetylation was reduced while histone tri-methylation was increased at specific lysine residues of H3 and H4 within the Drd2 promoter in the striatum of aged mice. HDAC inhibitors, particularly VPA, restored striatal D2R protein levels and functionality and reversed age- and drug-related histone modifications at the Drd2 promoter. CONCLUSIONS These results suggest that epigenetic changes at the striatal Drd2 promoter drive age-related increases in antipsychotic side effect susceptibility, and HDAC inhibitors may be an effective adjunct treatment strategy to reduce side effects in aged populations.
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Affiliation(s)
- Janitza L. Montalvo-Ortiz
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Daniel W. Fisher
- Department of Neurology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Guadalupe Rodriguez
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Deyu Fang
- Department of Pathology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - John G. Csernansky
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Hongxin Dong
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Ward 7-103, Chicago, IL, 60611, USA.
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15
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Willeboordse F, Schellevis FG, Chau SH, Hugtenburg JG, Elders PJM. The effectiveness of optimised clinical medication reviews for geriatric patients: Opti-Med a cluster randomised controlled trial. Fam Pract 2017; 34:437-445. [PMID: 28334979 DOI: 10.1093/fampra/cmx007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Inappropriate drug use is a frequent problem in older patients and associated with adverse clinical outcomes and an important determinant of geriatric problems. Clinical medication reviews (CMR) may reduce inappropriate drug use. OBJECTIVE The aim of this study is to investigate the effectiveness of CMR on quality of life (QoL) and geriatric problems in comparison with usual care in older patients with geriatric problems in the general practice. METHODS We performed a cluster randomised controlled trial in 22 Dutch general practices. Patients of ≥65 years were eligible if they newly presented with pre-specified geriatric symptoms in general practice and the chronic use of ≥1 prescribed drug. The intervention consisted of CMRs which were prepared by an independent expert team and discussed with the patient by the general practitioner. Primary outcomes: QoL and the presence of self-reported geriatric problems after a follow-up period of 6 months. RESULTS 518 patients were included. No significant differences between the intervention and control group and over time were found for QoL, geriatric problems, satisfaction with medication and self-reported medication adherence. After 6 months the percentage of solved Drug Related Problems (DRPs) was significantly higher in the intervention group compared to the control group [B 22.6 (95%CI 14.1-31.1), P < 0.001]. CONCLUSION The study intervention did not influence QoL and geriatric problems. The higher percentage of solved DRPs in the intervention group did not result in effects on the patient's health. CMRs on a large scale seem not meaningful and should be reconsidered.
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Affiliation(s)
- Floor Willeboordse
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - François G Schellevis
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands
| | - Sek Hung Chau
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, Amsterdam, The Netherlands
| | - Jacqueline G Hugtenburg
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, Amsterdam, The Netherlands
| | - Petra J M Elders
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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16
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Hefner G, Shams MEE, Unterecker S, Falter T, Hiemke C. Inflammation and psychotropic drugs: the relationship between C-reactive protein and antipsychotic drug levels. Psychopharmacology (Berl) 2016; 233:1695-705. [PMID: 26032842 DOI: 10.1007/s00213-015-3976-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 05/19/2015] [Indexed: 12/12/2022]
Abstract
RATIONALE In psychiatric clinical practice, there is a need to identify psychotropic drugs whose metabolisms are prone to be altered with increased inflammatory activity in an individual patient. OBJECTIVES The aim of this study was to find out whether elevated serum levels (≥5 mg/l) of C-reactive protein (CRP), an established laboratory marker of infection and inflammation, are associated with increased serum concentrations of the atypical antipsychotic drugs clozapine, quetiapine, and risperidone. METHODS Therapeutic drug monitoring request forms of patients whose antipsychotic drug concentrations had been measured under conditions of normal (<5 mg/l) and pathological (>5 mg/l) levels of C-reactive protein were retrospectively screened. The serum concentrations in relation to the daily doses [concentration per dose (C/D) (ng/mL/mg)] and the metabolic ratios [ratio of concentrations (metabolite/drug)] were compared intraindividually by the Wilcoxon signed rank test. To the study effects of the intensity of infections on drug concentrations, C-reactive protein and C/D levels were submitted to Spearman's correlation analysis. RESULTS Elevated levels of C-reactive protein were found in 105 patients. They were significantly associated with elevated values in C/D for clozapine (n = 33, P < 0.01) and risperidone (n = 40, P < 0.01). A trend for an increase was found for quetiapine (n = 32, P = 0.05). Median increases were 48.0 % (clozapine), 11.9 % (quetiapine), and 24.2 % (active moiety of risperidone), respectively. CONCLUSIONS In patients who exhibit signs of inflammation or infection with increased C-reactive protein values during psychopharmacological treatment, especially under clozapine and risperidone, therapeutic drug monitoring is recommendable in order to minimize the risk of intoxications due to elevated drug concentrations.
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Affiliation(s)
- Gudrun Hefner
- Department of Psychiatry and Psychotherapy, University Medical Centre, Mainz, Germany. .,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Centre, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Mohamed E E Shams
- Department of Pharmaceutics, Faculty of Pharmacy, University of Mansoura, Mansoura, Egypt.,Department of Pharmacy Practice, College of Health Sciences, Ministry of Health, Muscat, Oman
| | - Stefan Unterecker
- Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| | - Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Centre, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Centre, Mainz, Germany
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17
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Nishtala PS, Salahudeen MS, Hilmer SN. Anticholinergics: theoretical and clinical overview. Expert Opin Drug Saf 2016; 15:753-68. [DOI: 10.1517/14740338.2016.1165664] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | - Sarah N. Hilmer
- Sydney Medical School, Royal North Shore Hospital and Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia
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18
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Collamati A, Martone AM, Poscia A, Brandi V, Celi M, Marzetti E, Cherubini A, Landi F. Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence. Aging Clin Exp Res 2016; 28:25-35. [PMID: 25930085 DOI: 10.1007/s40520-015-0359-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/01/2015] [Indexed: 11/29/2022]
Abstract
The use of medication with anticholinergic properties is widespread among older subjects. Many drugs of common use such as antispasmodics, bronchodilators, antiarrhythmics, antihistamines, anti-hypertensive drugs, antiparkinson agents, skeletal muscle relaxants, and psychotropic drugs have been demonstrated to have an anticholinergic activity. The most frequent adverse effects are dry mouth, nausea, vomiting, constipation, abdominal pain, urinary retention, blurred vision, tachycardia and neurologic impairment such as confusion, agitation and coma. A growing evidence from experimental studies and clinical observations suggests that drugs with anticholinergic properties can cause physical and mental impairment in the elderly population. However, the morbidity and management issues associated with unwanted anticholinergic activity are underestimated and frequently overlooked. Moreover, their possible relation with specific negative outcome in the elderly population is still not firmly established. The aim of the present review was to evaluate the relationship between the use of drugs with anticholinergic activity and negative outcomes in older persons. We searched PubMed and Cochrane combining the search terms "anticholinergic", "delirium", "cognitive impairment", "falls", "mortality" and "discontinuation". Medicines with anticholinergic properties may increase the risks of functional and cognitive decline, morbidity, institutionalization and mortality in older people. However, such evidences are still not conclusive probably due to possible confounding factors. In particular, more studies are needed to investigate the effects of discontinuation of drug with anticholinergic properties. Overall, minimizing anticholinergic burden should always be encouraged in clinical practice to improve short-term memory, confusion and delirium, quality of life and daily functioning.
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Affiliation(s)
- Agnese Collamati
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy
| | - Anna Maria Martone
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy
| | - Andrea Poscia
- Institute of Public Health, Catholic University of Sacred Heart, Rome, Italy
| | - Vincenzo Brandi
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy
| | - Michela Celi
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy
| | - Emanuele Marzetti
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy
| | | | - Francesco Landi
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy.
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19
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Reeves S, Bertrand J, D’Antonio F, McLachlan E, Nair A, Brownings S, Greaves S, Smith A, Taylor D, Howard R. A population approach to characterise amisulpride pharmacokinetics in older people and Alzheimer's disease. Psychopharmacology (Berl) 2016; 233:3371-81. [PMID: 27481049 PMCID: PMC4989015 DOI: 10.1007/s00213-016-4379-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 06/30/2016] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Current prescribing guidelines for the antipsychotic amisulpride are based largely on pharmacokinetic (PK) studies in young adults, and there is a relative absence of data on older patients, who are at greatest risk of developing adverse events. METHODS This study aimed to develop a population PK model for amisulpride specifically in older people, by combining data from a richly sampled phase 1, single (50 mg) dose study in healthy older people (n = 20, 65-79 years), with a clinical dataset obtained during off label, low-dose (25-75 mg daily) amisulpride prescribing in older people with Alzheimer's disease (AD) (n = 25, 69-92 years), as part of an observational study. RESULTS After introducing a scaling factor based on body weight, age accounted for 20 % of the inter-individual variability in drug clearance (CL), resulting in a 54 % difference in CL between those aged 65 and those aged 85 years, and higher blood concentrations in older patients. DISCUSSION These findings argue for the consideration of age and weight-based dose stratification to optimise amisulpride prescribing in older people, particularly in those aged 85 years and above.
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Affiliation(s)
- Suzanne Reeves
- Division of Psychiatry, University College London, London, W1T7NF, UK. .,Department of Old Age Psychiatry, Kings College London, London, UK.
| | - Julie Bertrand
- UMR 1137 IAME INSERM University Paris 7, France and Genetics Institute, University College London, London, UK
| | - Fabrizia D’Antonio
- Division of Psychiatry, University College London, London, W1T7NF UK ,Department of Old Age Psychiatry, Kings College London, London, UK
| | - Emma McLachlan
- Department of Old Age Psychiatry, Kings College London, London, UK
| | - Akshay Nair
- Division of Psychiatry, University College London, London, W1T7NF UK
| | - Stuart Brownings
- Department of Old Age Psychiatry, Kings College London, London, UK
| | - Suki Greaves
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Alan Smith
- South London and Maudsley NHS Foundation Trust, London, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, W1T7NF UK ,Department of Old Age Psychiatry, Kings College London, London, UK
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Yang JA, Garis J, Lowe P. Psychotherapeutic Treatment of Psychotic Disorders in Later Life. GEROPSYCH-THE JOURNAL OF GERONTOPSYCHOLOGY AND GERIATRIC PSYCHIATRY 2015. [DOI: 10.1024/1662-9647/a000124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Older adults exhibit psychotic symptoms for various reasons. Treatment may require medical and psychiatric intervention, family support, community services, etc. The role of psychotherapy, however, has received little attention. This article describes a psychotherapeutic approach to treating older adults with psychotic symptoms based on the literature and the authors’ own experience. The approach includes reaching out to identify individuals in need of help; clinical engagement to develop a working relationship; linkage with needed services; and helping individuals reduce the link between triggers and psychotic symptoms. Differences between treating a person with delusional disorder versus schizophrenia are discussed.
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Affiliation(s)
- Janet A. Yang
- Heritage Clinic, Center for Aging Resources, Pasadena, CA, USA
| | - Jamie Garis
- Heritage Clinic, Center for Aging Resources, Pasadena, CA, USA
| | - Phillip Lowe
- Heritage Clinic, Center for Aging Resources, Pasadena, CA, USA
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21
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Hefner G, Stieffenhofer V, Gabriel S, Palmer G, Müller KM, Röschke J, Hiemke C. Side effects related to potentially inappropriate medications in elderly psychiatric patients under everyday pharmacotherapy. Eur J Clin Pharmacol 2014; 71:165-72. [PMID: 25529227 DOI: 10.1007/s00228-014-1796-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Potentially inappropriate medication (PIM) is suggested to give rise to adverse drug events. To study this suggestion for elderly psychiatric patients, an observational analysis related prescription of PRISCUS PIMs and drug-induced side effects in old aged (≥65 years) psychiatric inpatients and outpatients under conditions of everyday pharmacotherapy. METHODS Request forms from a therapeutic drug monitoring (TDM) survey and medical files were screened for medication to identify PIMs of the PRISCUS list and assessed using the Udvalg for Kliniske Undersøgelser (UKU) side effect rating scale. RESULTS From 914 TDM request forms, data were available for 168 patients (64.3 % female). Patients (mean ± SD age 73.0 ± 5.5 years) received by mean 6.4 ± 3.9 drugs per day. More than half of them (53.0 %, n = 89) had at least one PIM, inpatients 0.9 ± 0.8 and outpatients 0.5 ± 0.7. Predominant PIMs were hypnotic drugs (69 %) in inpatients and antipsychotic drugs (35.6 %) in outpatients. The number of PIMs correlated with the total number of drugs administered per day (Spearman correlation coefficient 0.225, p < 0.01, CI 95 %). Side effects were documented for 106 patients (63 %). Severity of side effects did not correlate significantly (p > 0.05) with number of PIMs. However, only 6 of 77 patients who took no PRISCUS PIMs but 2 of 3 patients who took 3 PRISCUS PIMs exhibited severe side effects. CONCLUSIONS Though the prevalence for PIMs and side effects was high in old aged psychiatric inpatients and outpatients, PIMs could not be identified as major determinants of overall unwanted side effects. Nevertheless, prescription of PIMs should be minimized, especially of hypnotic drugs, to improve safety.
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Affiliation(s)
- Gudrun Hefner
- Department of Psychiatry and Psychotherapy, University Medical Center, Mainz, Germany,
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Willeboordse F, Hugtenburg JG, van Dijk L, Bosmans JE, de Vries OJ, Schellevis FG, Elders PJM. Opti-Med: the effectiveness of optimised clinical medication reviews in older people with 'geriatric giants' in general practice; study protocol of a cluster randomised controlled trial. BMC Geriatr 2014; 14:116. [PMID: 25407349 PMCID: PMC4240827 DOI: 10.1186/1471-2318-14-116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 10/30/2014] [Indexed: 11/10/2022] Open
Abstract
Background Inappropriate drug use has been identified as one of the most important problems affecting the quality of care in older people. Inappropriate drug use may increase the risk of the occurrence of ‘geriatric giants’ such as immobility, instability, incontinence and cognitive impairment. There are indications that clinical medication reviews (CMR) can reduce inappropriate drug use. However, CMRs have not yet been implemented at a large scale in primary care. An innovative medication review program in primary care will be developed which tackles the most important obstacles for a large scale implementation of CMRs. The aim of this study is to assess whether this CMR program is (cost-) effective compared with usual general practice care for older patients with geriatric symptoms with regard to quality of life and geriatric symptoms. Methods A cluster randomised controlled trial will be performed in 20 Dutch general practices including 500 patients. Patients of 65 years and older are eligible if they newly present with pre-specified geriatric symptoms in general practice and chronic use of at least one prescribed drug. GP practices will be stratified by practice size and randomly allocated to control (n = 10) or intervention group (n = 10). The intervention consists of CMRs which will be facilitated and prepared by an expert team consisting of a GP and a pharmacist. Primary outcome measures are patient’s quality of life and the presence of self-reported geriatric symptoms during a follow-up period of 6 months. Secondary outcomes are costs of healthcare utilisation, feasibility, number of drug related problems, medication adherence and satisfaction with medication. Discussion This study is expected to add evidence on the (cost-) effectiveness of an optimally facilitated, prepared and structured CMR in comparison with usual care in older patients who present a geriatric symptom to their GP. The strength of this study is that it will be conducted in daily clinical practice. This improves the possibilities to implement the CMRs in the primary care setting on a large scale. Trial registration Netherlands Trial register: NTR4264 Electronic supplementary material The online version of this article (doi:10.1186/1471-2318-14-116) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Floor Willeboordse
- NIVEL, Netherlands Institute for Health Services Research, Po, Box 1568, 3500 BN, Utrecht, The Netherlands.
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Gerretsen P, Plitman E, Rajji TK, Graff-Guerrero A. The effects of aging on insight into illness in schizophrenia: a review. Int J Geriatr Psychiatry 2014; 29:1145-61. [PMID: 25055980 PMCID: PMC4472640 DOI: 10.1002/gps.4154] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 05/03/2014] [Accepted: 05/05/2014] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Impaired insight into illness is a prevalent feature of schizophrenia, which negatively influences treatment adherence and clinical outcomes. Little is known about the effects of aging on insight impairment. We aimed to review the available research literature on the effects of aging on insight into illness in schizophrenia, in relation to positive, negative, and cognitive symptoms. Ultimately, we propose a trajectory of insight in schizophrenia across the lifespan. METHOD A systematic Medline® literature search was conducted, searching for English language studies describing the relationship of insight into illness in schizophrenia with aging. RESULTS We identified 62 studies. Insight impairment is associated with illness severity, premorbid intellectual function (i.e. IQ), executive function, and memory. Insight impairment improves modestly during midlife, worsening again in late life. It tends to fluctuate with each episode of psychosis, likely in relation to worsening positive symptoms that improve with antipsychotic treatment. The relationship between insight impairment and cognitive dysfunction appears to attenuate with age, while the relationship with lower premorbid intellectual function is preserved. The association between impaired insight and negative symptoms is unclear. CONCLUSIONS The available literature suggests that the course of insight impairment follows a U-shaped curve, where insight impairment is severe during the first episode of psychosis, modestly improves over midlife, and declines again in late life. Future studies are required to investigate the trajectory of insight into illness and its core domains across the lifespan from prodromal phase to late life.
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Affiliation(s)
- Philip Gerretsen
- University of Toronto and the Centre for Addiction and Mental Health; Toronto ON Canada
| | - Eric Plitman
- University of Toronto and the Centre for Addiction and Mental Health; Toronto ON Canada
| | - Tarek K. Rajji
- University of Toronto and the Centre for Addiction and Mental Health; Toronto ON Canada
| | - Ariel Graff-Guerrero
- University of Toronto and the Centre for Addiction and Mental Health; Toronto ON Canada
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Genetic variation and the risk of haloperidol-related parkinsonism in elderly patients: a candidate gene approach. J Clin Psychopharmacol 2013; 33:405-10. [PMID: 23609402 DOI: 10.1097/jcp.0b013e3182902708] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Factors that influence the variation in occurrence of antipsychotic-related parkinsonism in elderly have not been well elucidated. The aim of this study was to investigate whether previous identified and studied genetic polymorphisms at DRD2, ANKK1, DRD3, HTR2A, HTR2C, RGS2, COMT, and BDNF genes are associated with antipsychotic-related parkinsonism in elderly patients.This cross-sectional study included 150 inpatients aged 65 years and older who were treated with haloperidol. Parkinsonism assessed by the Simpson Angus Scale was present in 46% of the included patients. The investigated predictors were polymorphisms in DRD2 (141CIns/Del and C957T), ANNK1 (TaqIA), DRD3 (Ser9Gly), HTR2A (-1438G>A and His452Tyr), HTR2C (Cys23Ser and -759C/T), RGS2 (+2971C>G), COMT (G158A), and BDNF (Val66Met). Frequencies of the -759 T allele of the HTR2C gene and the 158A allele of the COMT gene were significantly higher in patients without antipsychotic-induced parkinsonism (AIP) (nominal P = 0.03 and P = 0.02, respectively). -759 T allele carriership in females was associated with a lower risk of AIP (adjusted odds ratio, 0.31; 95% confidence interval, 0.11-0.85). The decrease in risk of AIP in carriers of the COMT 158A allele did not reach statistical significance. No significant associations were found between AIP and the remaining selected polymorphisms.Although validation is needed, this study suggests that carriership of the -759 T allele of the HTR2C gene in females may be protective against development of parkinsonism in elderly patients during treatment with haloperidol.
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Abstract
Many drugs commonly prescribed to the elderly have anticholinergic properties. Due to the current clinical use of drugs with mild-to-modest anticholinergic activity, the clinical manifestations of anticholinergic toxicity are likely to be nonspecific (e.g., cognitive impairment) and reflect the effects of cumulative anticholinergic burden. Age-associated physiological and pharmacokinetic changes increase anticholinergic drug effects in later life. Those with cognitive impairment and neurodegeneration are particularly susceptible to anticholinergic toxicity. Recent findings suggest that chronic anticholinergic burden may hasten or contribute to a neurodegenerative process. APOE ε4 carrier status may be a genetic risk factor for vulnerability to negative anticholinergic effects. There is no clinically available laboratory test to assess anticholinergic levels. Clinicians need to be cognizant of anticholinergic risks in later life. The use of clinical scales (e.g., Anticholinergic Drug Scale) and consensus guidelines (e.g., Revised Beers Criteria) may be helpful.
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Affiliation(s)
- Philip Gerretsen
- Geriatric Mental Health Program, Centre for Addiction & Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Faculty of Medicine, 33 Russell Street, T-109 Toronto, ON M5S 2S1, Canada
- Multimodal Imaging Group, Centre for Addiction & Mental Health, Toronto, ON, Canada
| | - Bruce G Pollock
- Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
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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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Grover S, Kumar V, Avasthi A, Kulhara P. First prescription of new elderly patients attending the psychiatry outpatient of a tertiary care institute in North India. Geriatr Gerontol Int 2011; 12:284-91. [DOI: 10.1111/j.1447-0594.2011.00767.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gerretsen P, Pollock BG. Drugs with anticholinergic properties: a current perspective on use and safety. Expert Opin Drug Saf 2011; 10:751-65. [DOI: 10.1517/14740338.2011.579899] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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