Concomitant use of analgesics and psychotropics in home-dwelling elderly people-Kuopio 75 + study

Potential active compounds and common mechanisms of Evodia rutaecarpa for Alzheimer's disease comorbid pain by network pharmacology analysis

Evodia rutaecarpa (Evodia) is a Chinese herbal medicine with analgesic and anti-neurodegenerative properties. However, whether Evodia compounds can be applied for the comorbid pain of Alzheimer's disease (AD) and the underlying mechanisms remain unclear. Herein, 137 common targets of Evodia between AD and pain were predicted from drug and disease target databases. Subsequently, protein-protein interaction (PPI) network, protein function module construction, and bioinformatics analyses were used to analyze the potential relationship among targets, pathways, and diseases. Evodia could simultaneously treat AD comorbid pain through multi-target, multi-component, and multi-pathway mechanisms, and inflammation was an important common phenotype of AD and pain. The relationship between important transcription factors such as RELA, NF-κB1, SP1, STAT3, and JUN on IL-17, TNF, and MAPK signaling pathways might be potential mechanisms of Evodia. Additionally, 10 candidate compounds were predicted, and evodiamine might be the effective active ingredient of Evodia in treating AD or pain. In summary, this study provided a reference for subsequent research and a novel understanding and direction for the clinical use of evodiamine to treat AD patients with comorbid pain.

The use of analgesics and associated factors among nursing home residents

Aim: This study examined the use of analgesics and associated factors among nursing home residents (NHRs). Materials & methods: A descriptive correlational design and a convenience sample of 209 NHRs receiving analgesics was used in this study. Results: Higher use of analgesics was noted among NHRs without cognitive impairment (p < 0.001), those with higher anticholinergic burden scores (p = 0.002) and those with a higher average number of oral pills taken daily (p = 0.045). Conclusion: These findings contribute to a better understanding of the prevalence and associated factors of analgesic use, which will inform the development and application of evidence-based pain practice and guidelines in nursing homes in Jordan and beyond.

Prevalence and persistent use of analgesic drugs in older adults receiving domiciliary care at baseline-A longitudinal study

AIMS

To describe the prevalence and persistence of analgesic drug use (opioids and antipyretics [ie, paracetamol and acetylsalicylic acid]) in participants (≥70 years) with and without dementia receiving domiciliary care in the eastern part of Norway. In addition, to explore factors associated with persistent drug use and examine whether drug use has changed after admission to a nursing home.

METHODS

A longitudinal study with 1001 participants (mean [SD] age 83.4 [5.7] years) receiving domiciliary care. Medical information including analgesic drug use was collected at baseline (A1) between August 2008 and December 2010, follow-up assessments after 18 (A2) and 36 months (A3). Analgesic drugs prescribed for regular use were recorded from the participants' medical records. The participants' cognitive and physical health was evaluated at all assessments. Level of care (domiciliary care or nursing home care) was recorded at A2 and A3. Generalized linear mixed models were used to examine the prevalence and persistence of analgesic drug use.

RESULTS

The prevalence of prescribed use of antipyretics and opioids was 13.6% and 9.2%, respectively. Participants with dementia had more frequent use of antipyretics in all assessments and opioids in the last assessment than participants without dementia. Persistent use of both antipyretics and opioids was high between two consecutive assessments, both for participants with and without dementia. Persistent use of analgesics was associated with poorer physical functioning, but not by level of care. Overall, there was no difference between those admitted to a nursing home and those receiving domiciliary care at follow-up, with respect to change in analgesic drug use over time.

CONCLUSION

The prevalence and persistent use of analgesics were high in older adults receiving domiciliary care at baseline and especially in participants with dementia. A holistic approach and interdisciplinary collaboration are essential to effectively assess and treat pain in older adults.

Association between psychotropic drug use and handgrip strength in older hospitalized patients

PURPOSE

Handgrip strength is an indicator of frailty and longevity in older adults. The association between psychotropic drug use and handgrip strength in older hospitalized patients was investigated in this study.

METHODS

A total of 488 patients were included in this retrospective cross-sectional study, 333 women and 155 men, from two different cohorts of older (mean age 84 years) hospitalized in-patients. We used multiple linear regression models to explore the association between psychotropic drug use and handgrip strength. We adjusted for factors known to affect handgrip strength: Age, gender, body mass index (BMI) and comorbidity (Charlson comorbidity index).

RESULTS

Both unadjusted and adjusted analyses showed that psychotropic drug use was associated with handgrip strength (β = - 0.183, p < 0.0001). The relationship was of a linear character, with no clear threshold value, but with the greatest reduction in handgrip strength between zero and two psychotropic drugs.

CONCLUSION

An increasing number of psychotropic drugs were significantly associated with reduced handgrip strength in a linearly pattern. Hence, it is timely to question the guided threshold value of avoidance of three or more psychotropic drugs in older people. Psychotropic drug use should be kept as low as possible in treatment of older patients.

Psychotropic Polypharmacy in Adults 55 Years or Older: A Risk for Impaired Global Cognition, Executive Function, and Mobility

Objectives

With their broad spectrum of action, psychotropic drugs are among the most common medications prescribed to the elderly. Consequently, the number of older adults taking multiple psychotropic drugs has more than doubled over the last decade. To improve knowledge about the deleterious effects of psychotropic polypharmacy, we investigated whether there is a threshold number of psychotropic molecules that could lead to impairment of global cognition, executive function, or mobility. Furthermore, relationships between the number of psychotropic molecules and cognitive and mobility impairment were examined.

Design

Cross-sectional study

Setting

University Hospital of Caen (France) and advertisements in medical offices

Participants

Community-dwelling older adults 55 years and older (n = 177; 69.8 ± 9.3 years; 81% women)

Measurements

Number of psychotropic molecules taken daily, global cognition assessed with the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA), processing speed with the Trail Making Test (TMT) A, executive function with the TMT B and TMT B-A, and mobility with the Time Up and Go (TUG). The threshold numbers of psychotropic molecules were determined by ROC curves analysis. Based on these threshold values, multinomial logistic regression adjusting for covariates was then performed.

Results

Logistic regressions showed that the threshold of two daily psychotropic molecules, identified by the ROC curves analysis, increases the risk of impaired executive function (p = .05 and.005 for the TMT B and TMT B-A, respectively), global cognition (p = .006 and.001 for the MMSE and MoCA, respectively), and mobility (p = .005 for the TUG), independent of confounding factors, including comorbidities. Furthermore, psychotropic polypharmacy would affect mobility through executive functions.

Conclusion

Impairment of global cognition, executive function, and mobility when as few as two psychotropic molecules are consumed in relatively healthy young older adults should alert physicians when prescribing combinations of psychotropic medications.

Pain assessment and pain treatment for community-dwelling people with dementia: A systematic review and narrative synthesis

OBJECTIVES

To describe the current literature on pain assessment and pain treatment for community-dwelling people with dementia.

METHOD

A comprehensive systematic search of the literature with narrative synthesis was conducted. Eight major bibliographic databases were searched in October 2018. Titles, abstracts, and full-text articles were sequentially screened. Standardised data extraction and quality appraisal exercises were conducted.

RESULTS

Thirty-two studies were included in the review, 11 reporting findings on pain assessment tools or methods and 27 reporting findings on treatments for pain. In regard to pain assessment, a large proportion of people with moderate to severe dementia were unable to complete a self-report pain instrument. Pain was more commonly reported by informal caregivers than the person with dementia themselves. Limited evidence was available for pain-focused behavioural observation assessment. In regard to pain treatment, paracetamol use was more common in community-dwelling people with dementia compared with people without dementia. However, non-steroidal anti-inflammatory drugs (NSAIDs) were used less. For stronger analgesics, community-dwelling people with dementia were more likely to receive strong opioids (eg, fentanyl) than people without dementia.

CONCLUSION

This review identifies a dearth of high-quality studies exploring pain assessment and/or treatment for community-dwelling people with dementia, not least into non-pharmacological interventions. The consequences of this lack of evidence, given the current and projected prevalence of the disease, are very serious and require urgent redress. In the meantime, clinicians should adopt a patient- and caregiver-centred, multi-dimensional, longitudinal approach to pain assessment and pain treatment for this population.

Prevalence and persistent use of psychotropic drugs in older adults receiving domiciliary care at baseline

Background

Little is known about the use of psychotropic drugs in older adults receiving domiciliary care. The first aim was to describe the prevalence and persistency of use of psychotropic drugs in older adults (≥ 70 years) with and without dementia receiving domiciliary care. Furthermore, the second aim was to explore factors associated with persistent drug use at two consecutive time-points. Lastly, we aimed to examine if use of psychotropic drugs changed after admission to a nursing home.

Methods

In total, 1001 community-dwelling older adults receiving domiciliary care at inclusion participated in the study. Information about psychotropic drug use was collected at baseline, after 18 months and after 36 months. The participants’ cognitive function, neuropsychiatric symptoms (NPS) and physical health were assessed at the same assessments. Participants were evaluated for dementia based on all gathered information. Formal level of care (domiciliary care or in a nursing home) was registered at the follow-up assessments.

Results

Prevalence and persistent use of psychotropic drugs in older adults receiving domiciliary care was high. Participants with dementia more often used antipsychotics and antidepressants than participants without dementia. The majority of the participants using antipsychotic drugs used traditional antipsychotics. Younger age was associated with higher odds for persistent use of antipsychotics and antidepressants, and lower odds for persistent use of sedatives. Severity of NPS was associated with persistent use of antidepressants. The odds for use of antipsychotics and antidepressants were higher in those admitted to a nursing home as compared to the community-dwelling participants at the last follow-up.

Conclusion

There was a high prevalence and persistency of use of psychotropic drugs. The prevalence of use of traditional antipsychotics was surprisingly high, which is alarming. Monitoring the effect and adverse effects of psychotropic drugs is an important part of the treatment, and discontinuation should be considered when possible due to the odds for severe adverse effects of such drugs in people with dementia.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1126-y) contains supplementary material, which is available to authorized users.

Chronic Pain in the Elderly with Cognitive Decline: A Narrative Review

The presence of pain in elderly persons with cognitive decline is often neglected, under-reported, underestimated, misdiagnosed and not adequately treated, with consequences that have a strong impact on health, independence in activities of daily living and quality of life. There is no empirical evidence that people with dementia experience less pain; therefore, in patients with severe cognitive impairment the progression of cognitive decline dramatically affects the ability to verbalize the presence of pain. Self-assessment scales are considered the “gold standard” for pain assessment, but the presence of cognitive impairment is likely to reduce the reliability of these measures. Treatment of pain in elderly with cognitive decline or dementia is based on non-pharmacological and pharmacological strategies. Pharmacological treatment should consider physiological changes, high comorbidity and drug interactions that occur frequently in the elderly. This narrative review aims to describe current knowledge, methods of detection and treatment approaches for chronic pain in elderly persons with cognitive deficits.

Categorization and association analysis of risk factors for adverse drug events

PURPOSE

Adverse drug events (ADE) are among the leading causes of morbidity and hospitalization. This review analyzes risk factors for ADE, particularly their categorizations and association patterns, the prevalence, severity, and preventability of ADE, and method characteristics of reviewed studies.

METHODS

Literature search was conducted via PubMed, Science Direct, CINAHL, and MEDLINE. A review was conducted of research articles that reported original data about specific risk factors for ADE since 2000. Data analyses were performed using Excel and R.

RESULTS

We summarized 211 risk factors for ADE, and grouped them into five main categories: patient-, disease-, medication-, health service-, and genetics-related. Among them, medication- and disease-related risk factors were most frequently studied. We further classified risk factors within each main category into subtypes. Among them, polypharmacy, age, gender, central nervous system agents, comorbidity, service utilization, inappropriate use/change use of drugs, cardiovascular agents, and anti-infectives were most studied subtypes. An association analysis of risk factors uncovered many interesting patterns. The median prevalence, preventability, and severity rate of reported ADE was 19.5% (0.29%~86.2%), 36.2% (2.63%~91%), and 16% (0.01%~47.4%), respectively.

CONCLUSIONS

This review introduced new categories and subtypes of risk factors for ADE. The broad and in-depth coverage of risk factors and their association patterns elucidate the complexity of risk factor analysis. Managing risk factors for ADE is crucial for improving patient safety, particularly for the elderly, comorbid, and polypharmacy patients. Some under-explored risk factors such as genetics, mental health and wellness, education, lifestyle, and physical environment invite future research.

An Evaluation of the Central Nervous System Medication Use and Frailty among Residents of Aged Care Homes in Malaysia

BACKGROUND/AIMS

Old age and institutionalization in care homes are associated with increased use of risk medications affecting the central nervous system (CNS). This study evaluated medication utilization and appropriateness; and assessed frailty among residents of Malaysian aged care homes.

METHODS

The subjects of this study included 202 elderly (≥65 years) residents of 17 aged care homes in suburban peninsular Malaysia. Frailty was measured using the Groningen Frailty Indicator (GFI) score and independence in daily living was measured as KATZ activity of daily living score. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI) and 2015 Beers' criteria for Potentially Inappropriate Medication (PIM).

RESULTS

CNS medications constituted about 16% of the total, with an average of 0.8 ± 1.1 medications per resident, which reduced to 0.5 ± 0.8 medications after 3 months. Frailty (154/202) and polypharmacy (90/202) were highly prevalent in study subjects. Subjects on CNS medications had significantly higher GFI score (7.1 vs. 5.9; p = 0.031), polypharmacy (57.8 vs. 35.3%; p = 0.002), number of PIMs (0.9 vs. 0.2; p = 0.001), and mean summed MAI score (3.6 vs. 2.6; p = 0.015) than subjects not on CNS medications. Medication number was also significantly correlated with GFI (r = 0.194; p = 0.006) and KATZ (r = 0.141; p = 0.046) scores.

CONCLUSION

Frailty and polypharmacy were highly prevalent among aged care home subjects taking CNS medications. These findings support the notion that periodic regular medication review should improve the overall use of medications in elderly patients.

[Opioids for noncancer pain in the elderly]

BACKGROUND

Opioids are increasingly used in the elderly. Side effects differ compared to other analgesics.

PURPOSE

In this review article, special aspects about using opioids for noncancer pain in older people and in geriatric patients are identified.

CURRENT SITUATION

So far randomized controlled trials for the indication of and comparison between various opioids have been performed in middle-aged patients and not exclusively in geriatric patients or elderly (> 75 years). Furthermore, the evidence for multimorbid elderly patients with respect to side effects is also very poor.

RECOMMENDATIONS

The indication for opioid therapy should be narrow. The patient and their caregivers must be provided patient information regarding opioid therapy. The principle "start low, go slow" is highly recommended. To reduce the risk of falls, longer acting opioids should be used and short acting opioids should be avoided. Everyday relevant negative effects on cognition are possible in opioid use and have to be observed. As recommended in the recently published German guideline for long-term use of opioids in noncancer pain a critical check after 3 months and in case of dosing over 120 mg morphine equivalents is advisable, especially for older patients. Liver and kidney function and drug interactions have to be taken into consideration like in every age group.

Psychotropic drug use among persons with mental distress symptoms: A population-based study in Norway

Aims: To explore psychotropic drug use in the general population and in particular among non-institutionalized persons with mental distress symptoms. Methods: A total of 14,139 women and 11,665 men participating in the Oslo Health Study or the Oppland/Hedmark Study 2000—2001 submitted a self-administered questionnaire on health status and drug use, lifestyle, and socioeconomic factors. Respondents using antidepressants, hypnotics, and/or anxiolytics during the last four weeks were defined as users. A high Hopkins Symptoms Checklist-10 score indicated mental distress. The 15% with the highest score in each gender and age group (adults: 30/40/45 years; elderly: 60 years) were studied. Results: The prevalence of antidepressant use among those with mental distress was, for women: adults 21%; elderly 30%; and for men, adults 15%; elderly 15%. These figures were nearly four times higher than in the general population. Not participating in the labour market was the main factor associated with use of antidepressants for subjects with mental distress: adult women (odds ratio (OR) 3.5; 95% confidence interval (CI) 2.5—5.0); elderly women (OR 5.2; CI 2.7—10.2); adult men (OR 4.7; CI 3.0—7.3); and elderly men (OR 2.9; CI 1.4—6.0). Use of analgesics was the main factor associated with use of anxiolytics/hypnotics: adult women (OR 2.4; CI 1.7—3.4); elderly women (OR 2.3; CI 1.4—3.8); adult men (OR 2.1; CI 1.3—3.3); and elderly men (OR 3.4; CI 1.9—6.0). Conclusions: Among individuals with mental distress, not participating in the labour market and regular use of analgesics were the main factors associated with use of psychotropics in both genders regardless of age.

The type and prevalence of the use of analgesics among inpatients in a geriatric psychiatry department

OBJECTIVES

The association between the presence of pain and mental disorder is well known. The extent of pain treatment in psychiatric patients is estimated to be high, but there is a lack of recent studies focusing on analgesic treatment in patients with mental disorders. The use of analgesics can be associated with side effects, and it is possible that analgesics are not the correct treatment for chronic pain among patients with mental disorders.

METHODS

Data were obtained among inpatients in a geriatric psychiatry department at Aarhus University Hospital, Risskov, Denmark, between 1 April 2013 and 1 October 2013. The study examines the extent of analgesic use by patients at admission with a follow up at discharge to note any change during hospitalization.

RESULTS

A total of 89 patients aged 68 years or older were included (56 women, 33 men). At admission, 51.7% used analgesics, and this number did not change significantly from admission to discharge. A statistically significant increased risk of analgesic use was found in females (odds ratio 4.0). The indications for analgesic use were not present in 34.5% of the pain-treated patients at admission. At discharge, this number had been reduced to 23.1%. Paracetamol was the drug most frequently used, followed by opioids.

CONCLUSIONS

The use of analgesics among aged psychiatric inpatients is high. An increased focus on this topic is recommended.

Time trends in 20 years of medication use in older adults: Findings from three elderly cohorts in Stockholm, Sweden

New drugs and expanded drug indications are constantly being introduced. Welfare states strive to provide equity in drug treatment for all of its citizens and todaýs healthcare systems spend financial resources on drugs for the elderly in a higher rate than for any other age group. Drug utilization in elderly persons has an impact in health and wellbeing in older people.

THE PURPOSE OF THE RESEARCH

It was to describe the changes in medication use including people aged 78 years and over regardless of residence and other characteristics over 20 years.

MATERIALS AND METHODS

The study population consisted of 4304 participants in three population-based cross-sectional surveys conducted in the Kungsholmen area of central Stockholm, Sweden. The participant's current drug utilization was reviewed by physicians following standardized protocols. Data were statistical analyzed. Logistic regression models was used to estimate odds ratios and 95% confidence intervals for use of analgesics and psychotropic drugs in the cohorts of 2001 and 2007, controlling for age, gender, education and cognition.

THE PRINCIPAL RESULTS AND MAJOR CONCLUSIONS

Results shows that the prevalence of medication use and polypharmacy in older adults has increased dramatically the late 1980s to the 2000s in central Stockholm, Sweden. In particular, the use of analgesics increased significantly, while some drug groups decreased, i.e., antipsychotics. Women used more medication than men in all three cohorts. Older adults living in service buildings used the largest amount of drugs in 1987, whereas those living in institutions were the most frequent users in 2001 and 2007.

Association between use of multiple psychoactive medicines and hospitalization for falls: retrospective analysis of a large healthcare claim database

Background

Little is known about the impact of taking multiple psychoactive medicines on the risk of hospitalization for falls.

Objective

To identify the association between multiple psychoactive medicine use and hospitalization for falls.

Methods

A retrospective cohort study was conducted between July 2011 and June 2012 in the Australian veteran population who had been dispensed at least one psychoactive medicine within the previous year. Psychoactive medicines with sedative properties included antipsychotics, anxiolytics, hypnotics, antidepressants, opioids, anti-epileptics, anti-Parkinson medicines and medicines for migraine. The associations between falls and the number of psychoactive medicines used or the number of doses were analysed in comparison with falls that occurred when no psychoactive medicine was used.

Results

The adjusted results showed a significantly increased risk of falls when patients were on one or more psychoactive medicines or were receiving 0.1–0.9 defined daily dose (DDD) or more per day. The incident rate ratios (IRRs) were 1.22 (95 % confidence interval [CI] 1.08–1.38) for those on one psychoactive medicine, 1.70 (95 % CI 1.45–1.99) for those on two, 1.96 (95 % CI 1.58–2.43) for those on three or four, and 3.15 (95 % CI 1.90–5.23) for those on five or more. A similar result was observed when the data were analysed by dose, with the highest risk being found for those taking three or more DDD per day (adjusted IRR 4.26, 95 % CI 2.75–6.58).

Conclusion

Increased numbers or increased doses of psychoactive medicines are associated with an increased risk of hospitalization for falls in older adults. Strategies to reduce the psychoactive medicine burden are likely to translate into significant health benefits.

Review on microbiota and effectiveness of probiotics use in older

The aim of the present systematic review is to summarize the existing knowledge about the human microbiota in the elderly and the effects of probiotics in elderly population. The elderly subjects, compared to adult population, show a reduction in the diversity of the microbiota, characterized by a large interindividual variability, with lower numbers of Firmicutes, Bifidobacteria, Clostridium cluster XIV, Faecalibacterium Prausnitzii, Blautia coccoides-Eubacterium rectal and higher presence of Enterobacteriaceae and Bacteroidetes. These differences of the intestinal microbiota of the elderly may not necessarily be caused by aging, but they could be associated with the decline of the general state of health with malnutrition and with increased need for medication, such as antibiotics and nonsteroidal anti-inflammatory drugs, situations that occur frequently in the elderly. Differences have been demonstrated in the composition of the microbiota between healthy elderly subjects and hospitalized or institutionalized elderly subjects. These findings which further indicates that the living conditions, health status, nutrition and drugs have a significant effect on the composition of the microbiota. According to the available knowledge, the use of probiotics is safe and could represent an useful intervention to prevent or treat antibiotic-associated diarrhea, in addition to reducing the severity of symptoms, other than to help the management of constipation.

Considerations in psychotropic treatments in dementia--can polypharmacy be avoided?

Physicians treating demented individuals are confronted with complex clinical presentations. This complexity results from the multi-factorial nature of clinical phenomena, the aetiologies of these phenomena, which differ from similar symptoms in younger populations, limited physiological reserves and the multiple co-morbidities and medications. This intricacy is well exemplified within the clinical presentation and management of psychological and behavioural symptoms of dementia. The latter are associated with a poor quality of life, increased burden for both patient and caregivers. A further challenge and source for frustration is the fact that many of the medications used to treat cognitive and behavioural symptoms of dementia are only marginally effective or not effective at all, on the one hand, and associated with increased risk for morbidity and mortality on the other hand. In the present review, we discuss these factors in the context of polypharmacy and suggest further clinical and research strategies that may enable more accurate and less harmful therapeutic strategies.

Prevalence of potential drug-drug interactions in cancer patients treated with oral anticancer drugs

BACKGROUND

Potential drug-drug interactions (PDDIs) in patients with cancer are common, but have not previously been quantified for oral anticancer treatment. We assessed the prevalence and seriousness of potential PDDIs among ambulatory cancer patients on oral anticancer treatment.

METHODS

A search was conducted in a computer-based medication prescription system for dispensing oral anticancer drugs to outpatients in three Dutch centres. Potential drug-drug interactions were identified using electronic (Drug Interaction Fact software) and manual screening methods (peer-reviewed reports).

RESULTS

In the 898 patients included in the study, 1359 PDDIs were identified in 426 patients (46%, 95% confidence interval (CI)=42-50%). In 143 patients (16%), a major PDDI was identified. The drug classes most frequently involved in a major PDDI were coumarins and opioids. The majority of cases concerned central nervous system interactions, PDDIs that can cause gastrointestinal toxicity and prolongation of QT intervals. In multivariate analysis, concomitant use of more drugs (odds ratio (OR)=1.66, 95% CI=1.54-1.78, P<0001) and genito-urinary cancer (OR=0.25, 95% CI=0.12-0.52, P<0001) were risk factors.

CONCLUSION

Potential drug-drug interactions are very common among cancer patients on oral cancer therapy. Physicians and pharmacists should be more aware of these potential interactions.

Potentially inappropriate drug use among older persons in Finland: application of a new national categorization

PURPOSE

The Finnish Medicines Agency published a new consensus categorization for potentially inappropriate drug (PID) use among persons aged 75 years and older (A = suitable, B = limited evidence, C = suitable for use under certain conditions only, D = inappropriate) in 2010. We investigated factors associated with use of one or more Category D drugs.

METHOD

Cross-sectional analyses were conducted using baseline data from the Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) Study collected in Kuopio, Finland, in 2004. From a random sample of 1000 persons aged 75 years and older, 781 persons provided consent to participate. Logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) and 95 % confidence intervals (95 % CIs) for factors associated with PID use.

RESULTS

PIDs were used by 30 % (n = 234) of all participants on a regular or as-needed basis. Among the 764 persons (98 %) who used prescription or non-prescription drugs, PID use was associated with the number of drugs in use (adjusted OR 1.20; 95 % CI 1.13-1.28) and moderate self-rated health compared to good self-rated health (adjusted OR 1.74; 95 % CI 1.19-2.55). PID use was associated with poor maximum walking speed (adjusted OR 1.64; 95 % CI 1.10-2.45), poor Timed Up and Go (TUG) test scores (adjusted OR 1.66; 95 % CI 1.11-2.47), impaired instrumental activities of daily living (adjusted OR 1.50; 95 % CI 1.06-2.12) and Mini Mental State Examination scores <18 (adjusted OR 2.27; 95 % CI 1.41-3.65).

CONCLUSION

PID use was highly prevalent and associated with impaired functional outcomes. This highlights the importance of clinicians conducting regular reviews of drug therapy.

Gut microbiota of healthy elderly NSAID users is selectively modified with the administration of Lactobacillus acidophilus NCFM and lactitol

Ageing changes gut microbiota composition and alters immune system function. Probiotics, prebiotics and synbiotics may improve the health status of elderly individuals by modifying the intestinal environment and the microbiota composition, and by stimulating the immune system. In this work, we studied the effects of synbiotic supplementation on the gut microbiota of healthy elderly volunteers. Fifty-one elders were randomly assigned to consume either a synbiotic dietary supplement or a placebo in addition to their usual diet for a 2-week period. The synbiotic product consisted of the probiotic Lactobacillus acidophilus NCFM and the prebiotic lactitol and was ingested twice a day, with a total daily dose of 10 g lactitol and 2 × 10(10) cells of probiotic bacteria. Before, during and after the intervention period fecal quantities of six phylogenetic bacterial groups were determined using quantitative PCR, and relative changes in total microbiota composition were assessed by percent guanine-plus-cytosine profiling. The microbiota profiles showed certain relative changes within the microbial community, and indicated an increase of bifidobacteria levels during synbiotic supplementation. Quantification by PCR confirmed the in changes in the microbiota composition; for example increases in total levels of endogenous bifidobacteria and lactobacilli were recorded. Throughout the 6-week study period there was a decrease unrelated to intervention in the Blautia coccoides-Eubacterium rectale bacterial group levels and Clostridium cluster XIVab levels, but this decrease appeared to be halted during the synbiotic intervention. In conclusion, putatively beneficial changes in microbiota were observed in the elderly subjects supplemented with the synbiotic product.

CNS medications as predictors of precipitous cognitive decline in the cognitively disabled aged: a longitudinal population-based study

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.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians. Part 2: special populations

OBJECTIVE

To provide family physicians with a practical clinical summary of opioid prescribing for specific populations based on recommendations from the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain.

QUALITY OF EVIDENCE

Researchers for the guideline conducted a systematic review of the literature, focusing on reviews of the effectiveness and safety of opioids in specific populations.

MAIN MESSAGE

Family physicians can minimize the risks of overdose, sedation, misuse, and addiction through the use of strategies tailored to the age and health status of patients. For patients at high risk of addiction, opioids should be reserved for well-defined nociceptive or neuropathic pain conditions that have not responded to first-line treatments. Opioids should be titrated slowly, with frequent dispensing and close monitoring for signs of misuse. Suspected opioid addiction is managed with structured opioid therapy, methadone or buprenorphine treatment, or abstinence-based treatment. Patients with mood and anxiety disorders tend to have a blunted analgesic response to opioids, are at higher risk of misuse, and are often taking sedating drugs that interact adversely with opioids. Precautions similar to those for other high-risk patients should be employed. The opioid should be tapered if the patient's pain remains severe despite an adequate trial of opioid therapy. In the elderly, sedation, falls, and overdose can be minimized through lower initial doses, slower titration, benzodiazepine tapering, and careful patient education. For pregnant women taking daily opioid therapy, the opioids should be slowly tapered and discontinued. If this is not possible, they should be tapered to the lowest effective dose. Opioid-dependent pregnant women should receive methadone treatment. Adolescents are at high risk of opioid overdose, misuse, and addiction. Patients with adolescents living at home should store their opioid medication safely. Adolescents rarely require long-term opioid therapy.

CONCLUSION

Family physicians must take into consideration the patient's age, psychiatric status, level of risk of addiction, and other factors when prescribing opioids for chronic pain.

Change in psychotropic drug use among community-dwelling people aged 75 years and older in Finland: repeated cross-sectional population studies

BACKGROUND

Older people are at high risk of experiencing psychotropic-related adverse drug events. The objective of this study was to compare and contrast the use of psychotropic drugs among community-dwelling people aged ≥ 75 years in 1998 and 2004.

METHODS

Comparable random samples of people aged ≥ 75 years were extracted from the population register in Kuopio, Finland, in 1998 (n = 700) and 2003 (n = 1000). In 1998 and 2004, 523 and 700 community-dwelling people respectively participated in nurse interviews, during which demographic, diagnostic and drug use data were elicited. Logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the prevalence of psychotropic drug use in 2004 compared to 1998.

RESULTS

The unadjusted prevalence of total psychotropic (37.3% and 38.4%, OR 1.05; 95% CI 0.83-1.33), anxiolytic, hypnotic and sedative (29.6% and 31.3%, OR 1.08, 95% CI 0.85-1.38), and antidepressant (10.7% and 11.9%, OR 1.12, 95% CI 0.78-1.61) use were similar in 1998 and 2004. There was a decrease in the unadjusted prevalence of antipsychotic use (9.2% and 5.7%, OR 0.60; 95% CI 0.39-0.93). After adjusting for socioeconomic and health status differences, there was an increase in the prevalence of total psychotropic (adjusted OR 1.31, 95% CI 1.01-1.70) and antidepressant (OR 1.59, 95% CI 1.06-2.40) use.

CONCLUSION

The unadjusted prevalence of psychotropic drug use remained stable between 1998 and 2004. However, in adjusted analyses there was a small increase in the prevalence of any psychotropic drug use and antidepressant use specifically.

Concomitant use of SSRIs, NSAIDs/aspirin and gastroprotective drugs among residents of long-term care facilities: a medical record review

BACKGROUND AND OBJECTIVES

Concomitant use of selective serotonin reuptake inhibitors (SSRIs) and nonsteroidal anti-inflammatory drugs (NSAIDs) [including aspirin (acetylsalicylic acid)] may potentiate the likelihood of upper gastrointestinal haemorrhage (UGIH). The objectives of this study were to determine the prevalence and factors associated with concomitant SSRI/NSAID use among residents of long-term care facilities, and to investigate the use of gastroprotective drugs among concomitant SSRI/NSAID users.

METHODS

The study sample comprised 1087 out of 1444 residents of all 53 long-term care wards in Helsinki, Finland, in September 2003. Data were extracted from residents' medication charts and medical records by trained nurses. Medication, diagnostic and mortality data were available for 1004 residents.

RESULTS

Among the 1004 residents (mean ± SD age 81.3 ± 10.9 years), 28% used an SSRI, 38% used an NSAID and 24% used a gastroprotective drug. Thirteen percent of residents were concomitant users of SSRIs/NSAIDs. Concomitant use was associated with diabetes mellitus (p < 0.001), previous stroke (p < 0.001) and a higher degree of co-morbidity (p < 0.001). Gastroprotective drugs were used by 27% of concomitant users of SSRIs/NSAIDs compared with 37%, 20% and 22% of SSRI users, NSAID users and non-users of SSRIs/NSAIDs, respectively. One-year all-cause mortality was similar among all groups.

CONCLUSION

The long-term facility residents in this study sample were frequently exposed to drug-drug interactions that potentiate the risk of UGIH. Only about one-quarter of concomitant users of SSRIs/NSAIDs were prescribed a gastroprotective drug. Further initiatives are needed to optimize the use of SSRIs, NSAIDs and gastroprotective drugs.

Potential drug interactions in cancer therapy: a prevalence study using an advanced screening method

BACKGROUND

In cancer patients, drug interactions may intensify adverse events or reduce antitumour effects. We assessed the prevalence of potential drug interactions (PDIs) among ambulatory cancer patients on i.v. treatment using an advanced screening method.

PATIENTS AND METHODS

Data on drugs used for comorbidities, anticancer agents, over-the-counter (OTC) drugs, and comorbidities were collected by means of a structured interview among the patients and review of medical charts. PDIs were identified using electronic (Drug Interaction Facts software, version 4.0) and manual screening methods (peer-reviewed reports).

RESULTS

In this study, 278 patients were enrolled. We identified 348 PDIs. Of all patients, 161 (58%) had at least one PDI. Of all PDIs, 34% was classified as major and 60% as moderate. Coumarins, quinolones, antiepileptics, and hydrochlorothiazide were frequently part of a PDI. Interactions that potentially cause QT interval prolongation, gastrointestinal toxicity, and central nervous system depression were also common. In multivariate analysis, an increasing number of drugs [odds ratio (OR) = 1.4, confidence interval (CI) 1.23-1.52; P < 0.001] and the use of an OTC drug (OR = 0.56, CI 0.32-0.97; P = 0.045) were risk factors.

CONCLUSIONS

PDIs are common in patients treated for an (haemato-) oncological disease. Screening for potential interactions should take place routinely before administering chemotherapy.

Combination drug therapy for chronic pain: a call for more clinical studies

Chronic pain is a debilitating clinical condition associated with a variety of disease entities including diabetic neuropathy, postherpetic neuralgia, low back pathology, fibromyalgia, and neurological disorders. For many general practitioners and specialists, managing chronic pain has become a daunting challenge. As a modality of multidisciplinary chronic pain management, medications are often prescribed in combinations, an approach referred to as combination drug therapy (CDT). However, many medications for pain therapy, including antidepressants and opioid analgesics, have significant side effects that can compound when used in combination and impact the effectiveness of CDT. To date, clinical practice of CDT for chronic pain has been based largely on clinical experiences. In this article, we will focus on (1) the scientific basis and rationales for CDT, (2) current clinical data on CDT, and (3) the need for more clinical studies to establish a framework for the use of CDT.

PERSPECTIVE

More preclinical, clinical, and translational studies are needed to improve the efficacy of combination drug therapy that is an integral part of a comprehensive approach to the management of chronic pain.

Potential drug interactions and duplicate prescriptions among ambulatory cancer patients: a prevalence study using an advanced screening method

BACKGROUND

The pharmacotherapeutic treatment of patients with cancer is generally associated with multiple side-effects. Drug interactions and duplicate prescriptions between anti-cancer drugs or interactions with medication to treat comorbidity can reinforce or intensify side-effects.The aim of the present study is to gain more insight into the prevalence of drug interactions and duplicate prescriptions among patients being treated in the outpatient day care departments for oncology and hematological illnesses. For the first time the prevalence of drug interactions with OTC-drugs in cancer patients will be studied. Possible risk factors for the occurrence of these drug-related problems will also be studied.

METHODS/DESIGN

A multicenter cross-sectional observational study of the epidemiology of drug interactions and duplicate prescriptions is performed among all oncology and hemato-oncology patients treated with systemic anti-cancer drugs at the oncology and hematology outpatient day care department of the VU University medical center and the Zaans Medical Center.

DISCUSSION

In this article the prevalence of potential drug interactions in outpatient day-care patients treated with anti-cancer agents is studied using a novel more extensive screening method. If this study shows a high prevalence of drug interactions clinical pharmacists and oncologists must collaborate to develop a pharmaceutical screening programme, including an automated electronic warning system, to support drug prescribing for ambulatory cancer patient. This programme could minimize the occurrence of drug related problems such as drug interactions and duplicate prescriptions, thereby increasing quality of life.

TRIAL REGISTRATION

This study is registered, number NTR2238.

Psychotropic drugs and the risk of fractures in old age: a prospective population-based study

BACKGROUND

There is evidence that the use of any psychotropic and the concomitant use of two or more benzodiazepines are related to an increased risk of fractures in old age. However, also controversial results exist. The aim was to describe associations between the use of a psychotropic drug, or the concomitant use of two or more of these drugs and the risk of fractures in a population aged 65 years or over.

METHODS

This study was a part of a prospective longitudinal population-based study carried out in the municipality of Lieto, South-Western Finland. The objective was to describe gender-specific associations between the use of one psychotropic drug [benzodiazepine (BZD), antipsychotic (AP) or antidepressant (AD)] or the concomitant use of two or more psychotropic drugs and the risk of fractures in a population 65 years or over. Subjects were participants in the first wave of the Lieto study in 1990-1991, and they were followed up until the end of 1996. Information about fractures confirmed with radiology reports in 1,177 subjects (482 men and 695 women) during the follow-up was collected from medical records. Two follow-up periods (three and six years) were used, and previously found risk factors of fractures were adjusted as confounding factors separately for men and women. The Poisson regression model was used in the analyses.

RESULTS

The concomitant use of two or more BZDs and the concomitant use of two or more APs were related to an increased risk of fractures during both follow-up periods after adjusting for confounding factors in men. No similar associations were found in women.

CONCLUSIONS

The concomitant use of several BZDs and that of several APs are associated with an increase in the risk of fractures in older men. Our findings show only risk relations. We cannot draw the conclusion that these drug combinations are causes of fractures.

Central nervous system medication use and incident mobility limitation in community elders: the Health, Aging, and Body Composition study

PURPOSE

To evaluate whether CNS medication use in older adults was associated with a higher risk of future incident mobility limitation.

METHODS

This 5-year longitudinal cohort study included 3055 participants from the health, aging and body composition (Health ABC) study who were well-functioning at baseline. CNS medication use (benzodiazepine and opioid receptor agonists, antipsychotics, and antidepressants) was determined yearly (except year 4) during in-home or in-clinic interviews. Summated standardized daily doses (low, medium, and high) and duration of CNS drug use were computed. Incident mobility limitation was operationalized as two consecutive self-reports of having any difficulty walking 1/4 mile or climbing 10 steps without resting every 6 months after baseline. Multivariable Cox proportional hazard analyses were conducted adjusting for demographics, health behaviors, health status, and common indications for CNS medications.

RESULTS

Each year at least 13.9% of participants used a CNS medication. By year 6, overall 49% had developed incident mobility limitation. In multivariable models, CNS medication users compared to never users showed a higher risk for incident mobility limitation (adjusted hazard ratio (Adj. HR) 1.28; 95% confidence interval (CI) 1.12-1.47). Similar findings of increased risk were seen in analyses examining dose- and duration-response relationships.

CONCLUSIONS

CNS medication use is independently associated with an increased risk of future incident mobility limitation in community dwelling elderly. Further studies are needed to determine the impact of reducing CNS medication exposure on mobility problems.

Number of teeth and myocardial infarction and stroke among elderly never smokers

Background

In most previous studies the association between number of teeth and cardiovascular diseases has been found to be stronger among younger age groups than in older age groups, which indicates that age may modify the association between number of teeth and cardiovascular diseases.

We investigated the association between tooth loss and atherosclerotic vascular diseases such as myocardial infarction and stroke in a homogeneous elderly population.

The study population was comprised of a subpopulation of 392 community-living elderly people who participated in the population-based Kuopio 75+ study. The data were collected through an interview, a structured clinical health examination and from patient records. The main outcome measures were a history of diagnosed myocardial infarction and diagnosed ischemic stroke. Prevalence proportion ratios (PPR) were estimated using generalised linear models.

Results

Edentate subjects had a weakly, statistically non-significantly increased likelihood of a history of myocardial infarction and ischemic stroke compared with dentate subjects. Those with a large number of teeth had a slightly, but not statistically significantly increased likelihood of a history of myocardial infarction and ischemic stroke compared with those with a small number of teeth.

Conclusion

These data did not show evidence that total or partial tooth loss would be associated with atherosclerotic vascular diseases such as myocardial infarction and ischemic stroke among an elderly population aged 75 years or older.

Number and dosage of central nervous system medications on recurrent falls in community elders: the Health, Aging and Body Composition study

BACKGROUND

Few studies have examined the risk of multiple or high doses of combined central nervous system (CNS) medication use for recurrent falls in the elderly. The study objective was to evaluate whether multiple- or high-dose CNS medication use in older adults was associated with a higher risk of recurrent (>or=2) falls.

METHODS

This longitudinal cohort study included 3,055 participants from the Health, Aging and Body Composition study who were well functioning at baseline. CNS medication use (benzodiazepine and opioid receptor agonists, antipsychotics, antidepressants) was determined annually (except Year 4) during in-person interviews. The number and summated standard daily doses (SDDs; low, medium, and high) of CNS medications were computed. Falls 1 year later were ascertained annually for 5 years.

RESULTS

For a period of 5 years, as many as 24.1% of CNS medication users took 2+ agents annually, whereas as no more than 18.9% of CNS medication users took high doses annually (3+ SDDs). Yearly, as many as 9.7% of participants reported recurrent falls. Multivariable Generalized Estimating Equation analyses showed that multiple CNS medication users compared with never users had an increased risk of sustaining 2+ falls (adjusted odds ratio [OR] 1.95; 95% confidence interval [CI] 1.35-2.81). Those taking high (3+) CNS SDDs also exhibited an increased risk of 2+ falls (adjusted OR 2.89; 95% CI 1.96-4.25).

CONCLUSIONS

Higher total daily doses of CNS medications were associated with recurrent falls. Further studies are needed to determine the impact of reducing the number of CNS medications and/or dosage on recurrent falls.

Influence of a combination of Lactobacillus acidophilus NCFM and lactitol on healthy elderly: intestinal and immune parameters

With increasing age, a number of physiological changes take place which are reflected in immune and bowel function. These changes may relate to the commonly assumed age-related changes in intestinal microbiota; most noticeably a reduction in bifidobacteria. The current study aimed at modifying the intestinal microbiota with a potential synbiotic on selected immune and microbiota markers. Healthy elderly subjects were randomised to consume during 2 weeks either a placebo (sucrose) or a combination of lactitol and Lactobacillus acidophilus NCFM twice daily in a double-blind parallel trial. After the intervention, stool frequency was higher in the synbiotic group than in the placebo group and a significant increase in faecal L. acidophilus NCFM levels was observed in the synbiotic group, after baseline correction. In contrast to the generally held opinion, the study subjects had faecal Bifidobacterium levels that were similar to those reported in healthy young adults. These levels were, nevertheless, significantly increased by the intervention. Levels of SCFA were not changed significantly. Of the measured immune markers, PGE2 levels were different between treatments and IgA levels changed over time. These changes were modest which may relate to the fact that the volunteers were healthy. Spermidine levels changed over time which may suggest an improved mucosal integrity and intestinal motility. The results suggest that consumption of lactitol combined with L. acidophilus NCFM twice daily may improve some markers of the intestinal microbiota composition and mucosal functions.

Estimation of psycholeptic and psychoanaleptic medicine use in an adult general population sample using the Anatomical Therapeutic Chemical classification

Little is known about psycholeptic and psychoanaleptic medicine (PM) use in the general population. This study presents prevalence data about PM use. The sample included 4310 individuals aged 20-79 from a general population health examination in a northern German area (participation proportion: 68.8%; Study of Health in Pomerania, SHIP). Medicines taken during the past seven days were assessed from the medicine packages or self-reports and classified according to the Anatomical Therapeutic Chemical (ATC) classification developed by the World Health Organization. In total, 6.3% of the sample reported PM intake, 8.7% of the women and 4.7% of the men. During the past 12 months prior to the health examination, 49.2% of the individuals with PM use consulted a general practitioner but not a neurologist or a psychiatrist. Among the study participants with PM use, 88.8% had one or more mental disorders during lifetime according to a screening questionnaire. It is concluded that considerable proportions of individuals with current PM use exist although lower than may be expected on the basis of the number of individuals with mental disorder in the general population.

School injury and gender differentials: a prospective cohort study

This study assessed the role of certain individual characteristics in school injury among male and female adolescents. The sample included 2,398 subjects attending middle schools and high schools. Respondents completed a self-administered questionnaire at the beginning of the school year. School nurse completed a questionnaire on injury for each school injury occurred during the school year. The data was analyzed with the adjusted odds ratios (ORa) computed via the logistic models. The school injury was common (13% for both sexes). Sports/physical training injury was more frequent among girls (8.8% vs. 6.6%, P < 0.05) contrarily to the other types of injury (4.6% vs. 8.8%, P = 0.001). Sports/physical training injury was strongly associated with age <15 years (ORa 3.42) and presence of previous injury (2.63) among boys, and with age <15 years (2.02), presence of previous injury (2.94), not easily irritated (1.89), and irresponsible (1.59) among girls. The other types of injury were highly related to age <15 years (ORa 4.18), frequent use of psychotropic drugs (1.76), not living with both parents (1.65), being not calm (2.03), and presence of previous injury (1.82) among boys, and to age <15 years (2.59), obesity (3.24), and being not calm (1.84) among girls. The present study identified a number of potential risk factors for school injury among male and female adolescents. Preventive measures should be taken to make adolescents, their parents and teachers more aware of the risks and to find remedial measures.

Drug-Related Problems in the Community Setting

BACKGROUND AND OBJECTIVE

Adverse drug events are a leading cause of morbidity in Australia and internationally. People taking psychotropic drugs for mental illnesses may be particularly susceptible. This study aimed to classify and describe pharmacists' Home Medicines Review (HMR) findings and recommendations for people with mental illnesses.

METHODS

This was a descriptive study conducted from March to November 2003. General practitioners and community pharmacists practising in two regions of metropolitan Sydney were invited to participate. General practitioners recruited and referred community-dwelling people with mental illnesses to receive HMRs conducted by accredited pharmacists. Reviewing pharmacists interviewed 49 people in their homes. During the interviews the pharmacists provided drug information, assessed drug knowledge and beliefs, and assessed drug adherence. Pharmacists then produced written referenced reports that outlined drug-, patient- and prescriber-related findings and recommendations. These findings and recommendations were presented to the referring general practitioners at follow-up case conferences.

MAIN OUTCOME MEASURES

Drugs were classified using the Anatomical Therapeutic Chemical Classification System. Pharmacists' findings and recommendations were classified using the Clinical Pharmacy Activity Classification System.

RESULTS

The most common types of nervous system drugs taken by people who received a HMR were antidepressants (n = 39.33%), analgesics (n = 29.24%) and antipsychotics (n = 17.14%). Pharmacists reported 403 findings and made 360 recommendations for 49 people, with 90% of recommendations being accepted by the referring general practitioners. The most common findings related to potential adverse drug reactions (n = 53, for 47% of people), suspected adverse drug reactions (n = 48, for 55% of people), potential interactions (n = 30, for 37% of people), and people taking additional drugs unbeknown to their referring general practitioner (n = 26, for 25% of people). The most common recommendations were to switch a drug (n = 37, for 49% of people), suggest a non-drug treatment (n = 29, for 41% of people) and to suggest a new drug (n = 27, for 49% of people). At the time of referral, general practitioners documented people to be taking 7.8 +/- 4.4 (mean +/- SD) drugs each (range 1-18). Following home interviews, pharmacists determined people to be taking 9.1 +/- 4.8 drugs (range 1-20). This difference was statistically significant (p < 0.001).

CONCLUSIONS

Pharmacists identified a high incidence of drug-related problems among people receiving treatment for mental illnesses. Pharmacists also identified a higher incidence of overall drug use than documented by the referring general practitioners. HMRs and case conferences, undertaken collaboratively by general practitioners and pharmacists, may be a useful strategy to identify drug-related problems among people with mental illnesses.