Optimizing clinical outcomes in polypharmacy through poly-de-prescribing: a longitudinal study

Objectives

To evaluate polypharmacy in older people to determine whether the number of medications de-prescribed correlates with the extent of improvement in quality of life (QoL) and clinical outcomes.

Design

A prospective longitudinal cohort study of polypharmacy in people living in a community in Israel.

Setting

Participants aged 65 years or older who took at least six prescription drugs followed up for at least 3 years (range 3-10 years) after poly-de-prescription (PDP) recommendations.

Interventions

PDP recommended at first home visit using the Garfinkel algorithm. Annual follow-up and end-of-study questionnaires used to assess clinical outcomes, QoL, and satisfaction from de-prescribing. All medications taken, complications, hospitalizations, and mortality recorded. In total, 307 participants met the inclusion criteria; 25 incomplete end-of-study questionnaires meant 282 participants for subjective analysis. Participants divided into two subgroups: (i) those who discontinued more than 50% of the drugs (PDP group) or (ii) those who discontinued less than 50% of the drugs (non-responders, NR).

Main outcome measures

Objective: 3-year survival rate and hospitalizations. Subjective: general satisfaction from de-prescribing; change in functional, mental, and cognitive status; improved sleep quality, appetite, and continence; and decreased pain.

Results

Mean age: 83 years (range 65-99 years). Mean number of drugs at baseline visit: 9.8 (range 6-20); 6.7 ± 2.0 de-prescribed in the PDP group (n = 146) and 2.2 ± 2.1 in the NR group (n = 161) (p < 0.001).No statistical difference between the groups in the 3-year survival rate and hospitalizations, but a significant improvement in functional and cognitive status and, in general, satisfaction from the intervention in the PDP group compared to the NR group. Improvement usually evident within the first 3 months and persists for several years.

Conclusion

Poly-de-prescribing in the older population has beneficial effects on several clinical outcomes with no detrimental effect on the rate of hospitalization and survival. The extent of improvement correlates with the extent of de-prescribing. Applying the Garfinkel algorithm globally may improve QoL in millions of patients, a clinical and economic win-win situation.

Poly-De-Prescribing to Treat Polypharmacy: Lowering the Flames of the First Iatrogenic Epidemic

BACKGROUND

There has been a rapid increase in vulnerable subpopulations of very old with co-morbidity, dementia, frailty, and limited life expectancy. Being treated by many specialists has led to an epidemic of inappropriate medication use and polypharmacy (IMUP) with negative medical and economic consequences. For most medications there are no evidence-based studies in older people and treatments are based on guidelines proven in much younger/healthier populations.

OBJECTIVES

To evaluate whether the benefits of reducing IMUP by poly-de-prescribing (PDP) outweighs the negative outcomes in older people with polypharmacy.

METHODS

The Garfinkel method and algorithm were used in older people with polypharmacy (≥ 6 prescription drugs).

RESULTS

We found that in nursing departments, of 331 drugs de-prescribed only 32 (10%) had to be re-administered. Annual mortality and severe complications requiring referral to acute care facility were significantly reduced in PDP (P < 0.002). In community dwelling older people, successful de-prescribing was achieved in 81% with no increase in adverse events or deaths. Those who de-prescribed ≥ 3 prescription drugs showed significantly more improvement in functional and cognitive status, sleep quality, appetite, serious complications, quality of life, and general satisfaction compared to controls who stopped ≤ 2 medications (P < 0.002). Rates of hospitalization and mortality were comparable. Clinical improvement by polydeprescribing was usually evident within 3 months and persisted for several years. The main barrier to polydeprescribing was physician's unwillingness to deprescribe (P < 0.0001).

CONCLUSIONS

Applying the Garfinkel method of PDP may improve the lives of older people and save money.

Deprescribing practices, habits and attitudes of geriatricians and geriatricians-in-training across Europe: a large web-based survey

PURPOSE

To provide an overview of the current deprescribing attitudes, practices, and approaches of geriatricians and geriatricians-in-training across Europe.

METHODS

An online survey was disseminated among European geriatricians and geriatricians-in-training. The survey comprised Likert scale and multiple-choice questions on deprescribing approaches and practices, deprescribing education and knowledge, and facilitators/barriers of deprescribing. Responses to the survey questions and participant characteristics were quantified and differences evaluated between geriatricians and geriatricians-in-training and between European regions.

RESULTS

The 964 respondents (median age 42 years old; 64% female; 21% geriatricians-in-training) were generally willing to deprescribe (98%) and felt confident about deprescribing (85%). Despite differences across European regions, the most commonly reported reasons for deprescribing were functional impairment and occurrence of adverse drug reactions. The most important barriers for deprescribing were patients' unwillingness, fear of negative consequences, lack of time, and poor communication between multiple prescribers. Perceived risk of adverse drug reactions was highest for psychotropic drugs, nonsteroidal anti-inflammatory drugs, cardiovascular drugs, and opioid analgesics. Only one in four respondents (23% of geriatricians and 37% of geriatricians-in-training) think education in medical school had sufficiently prepared them for deprescribing in clinical practice. They reported that their future deprescribing activities would probably increase with improved information sharing between various prescribers, deprescribing recommendations in guidelines, and increased education and training. Approximately 90% think that a paradigm shift is required for prescribers and patients, increasing focus on the possible benefits of deprescribing (potentially) inappropriate medications.

CONCLUSIONS

Based on the outcomes of this survey, we recommend investing in improved inter-professional communication, better education and evidence-based recommendations to improve future patient-centered deprescribing practices.

[RATIONAL DE-PRESCRIBING TO TREAT POLYPHARMACY - COUNTERING THE FIRST IATROGENIC EPIDEMIC]

Improved medical technology is associated with rapidly growing sub-populations suffering from incurable co-morbidities for prolonged periods of time before death. Although there is no evidence based medicine (EBM) proving positive benefit/risk ratios for most medications in these sub-populations, it is evident that they are attended by an increased number of specialists, each of whom add medications based on "their" guidelines. Eventually, more people suffer from inappropriate medication use and polypharmacy (IMUP); IMUP's negative medical, economic and social consequences represent the 21st-century iatrogenic pandemic. Many barriers interfere with attempts to de-prescribe: The myth "drugs=health" is a deep-rooted value; de-prescribing is automatically perceived negatively; physicians are not trained to de-prescribe; and discussing de-prescribing with the patient/family is time consuming. In an era of defensive medicine, physicians have fears of lawsuits, of patient/family's reactions, fears of not following all guideline recommendations, despite the age-related decrease in their benefit/risk ratio. Like other pandemics, combined international efforts are required in order to manage IMUP effectively. The International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP) was established and has begun sowing the seeds of global collaboration. Partnership with patients/families in decision-making is essential in geriatric-palliative ethical approaches, to overcome barriers to de-prescribing. Borrowing the language of epidemics, several approaches of "curing the infected" (reducing polypharmacy) were suggested; Israeli studies have proven improved functional, mental and cognitive status and patient/family satisfaction, following massive de-prescribing, compared with those who adhered to standard recommendations. "Immunization" (prevention), should concentrate on early education of professionals and laymen about IMUP and de-prescribing. Rational de-prescribing represents "a triple-win-win game"- improves life quality in the last years of life and has huge economic benefits.

Teaching physicians the GPGP method promotes deprescribing in both inpatient and outpatient settings

Background

In complex older patients, inappropriate medication use and polypharmacy (IMUP) are commonplace and increasing exponentially. Reducing IMUP is a challenge in multiple clinical contexts, including acute admission and family practice, due to several key barriers. In the global effort against this epidemic, educational programs geared toward changing physicians’ prescribing patterns represent an important means of promoting deprescribing.

Methods

This is a nonrandomized, controlled interventional study investigating polypharmacy outcomes and prescribing patterns in patients whose physicians were trained in the Good Palliative-Geriatric Practice (GPGP) method, an algorithm for the reduction of polypharmacy, with patients whose physicians were not. Training involved a one-time, full-day workshop led by a senior geriatrician. Two separate settings were examined. In the inpatient setting, one internal medicine ward was trained and compared with another ward which was not trained. In the family practice setting, 28 physicians were trained and compared with practices of 15 physicians not trained. Patients were above the age of 70, representative of the general geriatric population, and not terminally ill.

Results

In the inpatient arm, the intervention group (n = 100) experienced a decrease in medications prescribed from admission to discharge of 18.5%, compared with a decrease of 1.9% in the control group (n = 100, difference between groups p < 0.0001). In the outpatient arm, the intervention group (n = 100) experienced a decrease in medication number of 6.1% compared with 0.07% in the control group (n = 100, difference between groups p = 0.001) over a 6-month period. Preferential decreases in specific drug classes were observed in both groups, including benzodiazepines, psychotropics, and antihypertensives.

Conclusions

A one-time educational intervention based on GPGP can change prescribing patterns in both outpatient and inpatient settings leading to a moderate reduction in polypharmacy. Future work should focus on longitudinal interventions, and longer-term clinical outcomes such as morbidity, mortality, and quality of life.

International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP): Position Statement and 10 Recommendations for Action

Globally, the number of drug prescriptions is increasing causing more adverse drug events, which is now a significant cause of mortality, morbidity, and disability that has reached epidemic proportions. The risk of adverse drug events is correlated to very old age, multiple co-morbidities, dementia, frailty, and limited life expectancy, with the major contributor being polypharmacy. Each characteristic alters the risk-benefit balance of medications, typically reducing anticipated benefits and amplifying risk. Current clinical guidelines are based on evidence proven in younger/healthier adult populations using a single disease model and their application to older adults with multimorbidity, in whom testing has not been conducted, yields a different risk-benefit prospect and makes inappropriate medication use and polypharmacy inevitable. Applying inappropriate clinical practice guidelines to older adults is antithetical to good healthcare, is likely to increase health inequity, and is associated with substantial negative clinical, economic, and social implications for health systems. The casualties are on the scale of a war or epidemic, yet are usually invisible in measures of healthcare quality and formal recommendations. Radical and rapid action is required to achieve a better quality of life for older populations and to remain true to the principles of medical professionalism and evidence-based medicine that place patients' interests and autonomy at the fore. This first International Group for Reducing Inappropriate Medication Use & Polypharmacy position statement briefly details the causes, consequences, and extent of inappropriate medication use and polypharmacy. This article outlines current strategies to reduce inappropriate medication use, provides evidence for their effect, and then proposes recommendations for moving forward with 10 recommendations for action and 12 recommendations for research. We conclude that an urgent integrated effort to reduce inappropriate medication use and polypharmacy should be a leading global target of the highest priority. The cornerstone of this position statement from the International Group for Reducing Inappropriate Medication Use & Polypharmacy is the understanding that without evidence of definite relevant benefit, when it comes to prescribing, for many older patients 'less is more'. This approach differs from most other current recommendations and guidance in medical care, as the focus is on what, when, and how to stop, rather than on when to start medications/interventions. Disrupting the framework that indiscriminately applies standard guidelines to older adults requires a new approach that better serves patients with multimorbidity. This transition requires a shift in medical education, research, and diagnostic frameworks, and re-examination of the measures used as quality indicators. In achieving this objective, we promote a return to some of the original concepts of evidence-based medicine: which considers scientific data (where it exists), clinical judgment, patient/family preference, and context. A shift is needed: from the current model that focuses on single conditions to one that simultaneously considers multiple conditions and patient priorities. This approach reframes the clinician's role as a professional providing care, rather than a disease technician.

Inappropriate medication use and polypharmacy in end-stage cancer patients: Isn't it the family doctor's role to de-prescribe much earlier?

BACKGROUND

Elderly patients are exposed to increased number of medications, often with no proof of a positive benefit/risk ratio. Unfortunately, this trend does not spare those with limited life expectancy, including end-stage cancer patients who require only palliative treatment. For many medications in this subpopulation, the risk of adverse drug events outweighs the possible benefits and yet, many are still poly-medicated during their last year of life.

AIM

To describe the extent of polypharmacy among end-stage cancer patients, at the time of admission to homecare hospice.

METHODS

A retrospective chart review of 202 patients admitted to Homecare Hospice of the Israel Cancer Association and died before January 2015.

RESULTS

Average lifespan from admission until death was 39.2 ± 5.4 days. 63% died within the first month, 89% within 3 months. Excluding oncological treatments, 181 (90%) and 46 (23%) patients were treated with ≥ 6 and ≥ 12 drugs for chronic diseases, respectively. Two months before death, 32 (16%) patients were treated with ≥ 3 blood pressure lowering drugs, 62 (31%) with statins and 48 (23%) with aspirin.

CONCLUSION

Though not representative of the whole end-stage cancer patient population, our study demonstrates that these patients are exposed to extensive polypharmacy. Most of these medications could have probably been safely de-prescribed much earlier in the course of the malignant disease. Considering the prolonged trust-based relationship with their patients, the family physicians are those who should be encouraged to implement the palliative approach and reduce polypharmacy much before reaching hospice settings.

Poly-de-prescribing to treat polypharmacy: efficacy and safety

BACKGROUND

The aim of this study was to evaluate efficacy and safety of poly-de-prescribing (PDP) based on the Garfinkel method in older people with polypharmacy.

METHODS

A longitudinal, prospective, nonrandomized study in Israel was carried out between 2009 and 2016. Comprehensive geriatric assessments were performed at home in people age ⩾66 years consuming ⩾6 prescription drugs. Exclusion criteria were life expectancy <6 months and a seeming unwillingness to cooperate (poor compliance). PDP of ⩾3 prescription drugs was recommended. Follow up was at ⩾3 years. Between April 2015 and April 2016 Likert scale questionnaires were filled by all participants/families to evaluate overall satisfaction and clinical outcomes. The outcome measures were change in functional, mental and cognitive status, sleep quality, appetite, continence; major complication, hospitalizations, mortality, and family doctor's cooperation.

RESULTS

Poly-de-prescribing of ⩾3 drugs was eventually achieved by 122 participants (PDP group); ⩽2 drugs stopped by 55 'nonresponders' (NR group). The average age was 83.4 ± 5.3 in the PDP group, and 80.8 ± 6.3 in the NR group (p = 0.0045). Follow up was 43.6 ± 14 months (PDP) and 39.5 ± 16.6 months (NR) (p = 0.09). The prevalence of most diseases/symptoms was comparable except for a higher prevalence for dementia, incontinence and functional decline in the PDP group. The main barrier to de-prescribing was the family doctor's unwillingness to adopt PDP recommendations (p < 0.0001). The baseline median number of medications taken by both groups was 10 (IQR 8 to 12) (p = 0.55). On the last follow up, the drug count was 11 (IQR 8 to 12) in the NR group and 4 (IQR 2 to 5) in the PDP group (p =0.0001). The PDP group showed significantly less deterioration (sometimes improvement) in general satisfaction, functional, mental and cognitive status, sleep quality, appetite, sphincter control, and the number of major complications was significantly reduced (p < 0.002 in all). The rate of hospitalizations and mortality was comparable. Health improvement occurred within 3 months after de-prescribing in 83%, and persisted for ⩾2 years in 68%.

CONCLUSIONS

This self-selected sample longitudinal research strongly suggests that the negative, usually invisible effects of polypharmacy are reversible. PDP is well tolerated and associated with improved clinical outcomes, in comparison with outcomes of older people who adhere to all clinical guidelines and take all medications conventionally. Future double-blind studies will probably prove beneficial economic outcomes as well.

Overview of current and future research and clinical directions for drug discontinuation: psychological, traditional and professional obstacles to deprescribing

The vicious circle of age-related diseases, many experts and guidelines/drugs fuels the 21st century iatrogenic epidemic of inappropriate medication use and polypharmacy. There are no evidence-based medicine (EBM) 'guidelines' for treating older people, and knowledge gaps regarding dosage requirements. For all drugs, the positive benefit/risk ratio is decreasing/inverted in correlation to very old age, comorbidity, dementia, frailty and limited life-expectancy (VOCODFLEX). Main obstacles to routine deprescribing are emotional/psychological myths; patient-doctor interactions are expected to be transformed into prescription; doctors are perceived as expert prescribers who wisely choose the right medication/s to treat all diseases. Although most 'guidelines' were not proven in older people, particularly VOCODFLEX, doctors are afraid of lawsuits and of the patient/family reaction if they do not follow all experts' recommendations. Doctors are frustrated facing uncertainty regarding the effectiveness of strategies to reduce polypharmacy and the lack of EBM indicating when to de-prescribe. When explicit criteria and 'drugs to avoid' are used alone, we may disregard undiagnosed harms imposed by the remaining drug groups and interactions. The best approaches are implicit tools that take into consideration EBM data, clinical circumstances and medical judgement. The Garfinkel Good Palliative-Geriatric Practice method recommends deprescribing of as many drugs as possible simultaneously, giving high priority to patient/family preferences. It was proven highly effective and safe in nursing departments and in community-dwelling elders, having significant economic benefits as well.

Efficacy and Safety of a Novel Autologous Wound Matrix in the Management of Complicated, Chronic Wounds: A Pilot Study

INTRODUCTION

The objective of this pilot study was to evaluate the efficacy and safety of a novel method using an autologous whole blood clot formed with the RedDress Wound Care System (RD1, RedDress Ltd, Israel), a provisional whole blood clot matrix used in the treatment of chronic wounds of various etiologies.

METHODS AND MATERIALS

Patients were treated at the bedside with the whole blood clot matrix. Blood was withdrawn from each patient using citrate, mixed with a calcium gluconate/kaolin suspension, and injected into an RD1 clotting tray. Within 10 minutes, a clot was formed, placed upon the wound, and fixed with primary and secondary dressings. Wounds were redressed weekly with a whole blood clot matrix. Treatment was terminated when complete healing was achieved, or when the clinician determined that the wound could not further improve without additional invasive procedures.

RESULTS

Seven patients with multiple and serious comorbidities and 9 chronic wounds were treated with 35 clot matrices. Complete healing was achieved in 7 of 9 wounds (78%). In 1 venous ulcer with a nonhealing fistula, 77% healing was achieved. Treatment was terminated in 1 pressure ulcer at 82% closure, because an unexpected mechanical trauma resulted in deterioration; this was the only adverse event reported, unrelated to the product. No systemic adverse events occurred.

CONCLUSIONS

This pilot study demonstrates the in vitro autologous whole blood clot matrix is effective and safe for treating patients with chronic wounds of different etiologies. A larger clinical trial is needed to assess the relative success rate of the matrix in different types of wounds in a diverse population with comorbidities.

Routine deprescribing of chronic medications to combat polypharmacy

The positive benefit-risk ratio of most drugs is decreasing in correlation to very old age, the extent of comorbidity, dementia, frailty and limited life expectancy (VOCODFLEX). First, we review the extent of inappropriate medication use and polypharmacy (IMUP) globally and highlight its negative medical, nursing, social and economic consequences. Second, we expose the main clinical/practical and perceptual obstacles that combine to create the negative vicious circle that eventually makes us feel frustrated and hopeless in treating VOCODFLEX in general, and in our 'war against IMUP' in particular. Third, we summarize the main international approaches/methods suggested and tried in different countries in an attempt to improve the ominous clinical and economic outcomes of IMUP; these include a variety of clinical, pharmacological, computer-assisted and educational programs. Lastly, we suggest a new comprehensive perception for providing good medical practice to VOCODFLEX in the 21st century. This includes new principles for research, education and clinical practice guidelines completely different from the 'single disease model' research and clinical rules we were raised upon and somehow 'fanatically' adopted in the 20th century. This new perception, based on palliative, geriatric and ethical principle, may provide fresh tools for treating VOCODFLEX in general and reducing IMUP in particular.

Prolonged-release melatonin for insomnia - an open-label long-term study of efficacy, safety, and withdrawal

Background

Prolonged-release melatonin (PRM) 2 mg is indicated for insomnia in patients aged 55 years and older. A recent double-blind placebo-controlled study demonstrated 6-month efficacy and safety of PRM in insomnia patients aged 18–80 and lack of withdrawal and rebound symptoms upon discontinuation.

Objective

To investigate the efficacy, safety, and withdrawal phenomena associated with 6–12 months PRM treatment.

Methods

Data from a prospective 6–12-month open-label study of 244 community dwelling adults with primary insomnia, who had participated in a placebo-controlled, double-blind dose-ranging trial of PRM. Patients received PRM nightly, followed by a 2-week withdrawal period. Main outcome measures were patient-reported sleep quality ratings (diary), adverse events, vital signs, and laboratory tests recorded at each visit, and withdrawal symptoms (CHESS-84 [Check-list Evaluation of Somatic Symptoms]). Nocturnal urinary 6-sulfatoxymelatonin excretion, a measure of the endogenous melatonin production, was assessed upon discontinuing long-term PRM.

Results

Of the 244 patients, 36 dropped out, 112 completed 6 months of treatment, and the other 96 completed 12 months of treatment. The mean number of nights by which patients reported sleep quality as “good” or “very good” was significantly higher during PRM than before treatment. There was no evidence of tolerance to PRM. Discontinuation of PRM was not associated with rebound insomnia or withdrawal symptoms; on the contrary, residual benefit was observed. PRM was well tolerated, and there was no suppression of endogenous melatonin production.

Conclusion

Results support the efficacy and safety of PRM in primary insomnia patients aged 20–80 throughout 6–12 months of continuous therapy. PRM discontinuation even after 12 months was not associated with adverse events, withdrawal symptoms, or suppression of endogenous melatonin production.

Efficacy and safety of prolonged-release melatonin in insomnia patients with diabetes: a randomized, double-blind, crossover study

BACKGROUND

Diabetes is a major comorbidity in insomnia patients. The efficacy and safety of prolonged-release melatonin 2 mg in the treatment of glucose, lipid metabolism, and sleep was studied in 36 type 2 diabetic patients with insomnia (11 men, 25 women, age 46-77 years).

METHODS

In a randomized, double-blind, crossover study, the subjects were treated for 3 weeks (period 1) with prolonged-release melatonin or placebo, followed by a one-week washout period, and then crossed over for another 3 weeks (period 2) of treatment with the other preparation. All tablets were taken 2 hours before bedtime for a period of 3 weeks. In an extension period of 5 months, prolonged-release melatonin was given nightly to all patients in an open-label design. Sleep was objectively monitored in a subgroup of 22 patients using wrist actigraphy. Fasting glucose, fructosamine, insulin, C-peptide, triglycerides, total cholesterol, high-density and low-density lipoprotein cholesterol, and some antioxidants, as well as glycosylated hemoglobin (HbA1c) levels were measured at baseline and at the end of the study. All concomitant medications were continued throughout the study.

RESULTS

No significant changes in serum glucose, fructosamine, insulin, C-peptide, antioxidant levels or blood chemistry were observed after 3 weeks of prolonged-release melatonin treatment. Sleep efficiency, wake time after sleep onset, and number of awakenings improved significantly with prolonged-release melatonin as compared with placebo. Following 5 months of prolonged-release melatonin treatment, mean HbA1c (±standard deviation) was significantly lower than at baseline (9.13% ± 1.55% versus 8.47% ± 1.67%, respectively, P = 0.005).

CONCLUSION

Short-term use of prolonged-release melatonin improves sleep maintenance in type 2 diabetic patients with insomnia without affecting glucose and lipid metabolism. Long-term prolonged-release melatonin administration has a beneficial effect on HbA1c, suggesting improved glycemic control.

Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy

BACKGROUND

Polypharmacy and inappropriate medication use is a problem in elderly patients, who are more likely to experience adverse effects from multiple treatments and less likely to obtain the same therapeutic benefit as younger populations. The Good Palliative-Geriatric Practice algorithm for drug discontinuation has been shown to be effective in reducing polypharmacy and improving mortality and morbidity in nursing home inpatients. This study reports the feasibility of this approach in community-dwelling older patients.

METHODS

The Good Palliative-Geriatric Practice algorithm was applied to a cohort of 70 community-dwelling older patients to recommend drug discontinuations. Success rates of discontinuation, morbidity, mortality, and changes in health status were recorded.

RESULTS

The mean (SD) age of the 70 patients was 82.8 (6.9) years. Forty-three patients (61%) had 3 or more and 26% had 5 or more comorbidities. The mean follow-up was 19 months. Participants used a mean (SD) of 7.7 (3.7) medications. Protocol indicated that discontinuation was recommended for 311 medications in 64 patients (58% of drugs; mean [SD], 4.4 [2.5] drugs per patient overall, 4.9 per patient who had discontinuation). Of the discontinued drug therapies, 2% were restarted because of recurrence of the original indication. Taking nonconsent and failures together, successful discontinuation was achieved in 81%. Ten elderly patients (14%) died after a mean follow-up of 13 months, with the mean age at death of 89 years. No significant adverse events or deaths were attributable to discontinuation, and 88% of patients reported global improvement in health.

CONCLUSIONS

It is feasible to decrease medication burden in community-dwelling elderly patients. This tool would be suitable for larger randomized controlled trials in different clinical settings.

The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people

BACKGROUND

The extent of medical and financial problems of polypharmacy in the elderly is disturbing, particularly in nursing homes and nursing departments.

OBJECTIVES

To improve drug therapy and minimize drug intake in nursing departments.

METHODS

We introduced a geriatric-palliative approach and methodology to combat the problem of polypharmacy. The study group comprised 119 disabled patients in six geriatric nursing departments; the control group included 71 patients of comparable age, gender and co-morbidities in the same wards. After 12 months, we assessed whether any change in medications affected the death rate, referrals to acute care facility, and costs.

RESULTS

A total of 332 different drugs were discontinued in 119 patients (average of 2.8 drugs per patient) and was not associated with significant adverse effects. The overall rate of drug discontinuation failure was 18% of all patients and 10% of all drugs. The 1 year mortality rate was 45% in the control group but only 21% in the study group (P < 0.001, chi-square test). The patients' annual referral rate to acute care facilities was 30% in the control group but only 11.8% in the study group (P < 0.002). The intervention was associated with a substantial decrease in the cost of drugs.

CONCLUSIONS

Application of the geriatric-palliative methodology in the disabled elderly enables simultaneous discontinuation of several medications and yields a number of benefits: reduction in mortality rates and referrals to acute care facilities, lower costs, and improved quality of living.

Improvement of sleep quality by controlled-release melatonin in benzodiazepine-treated elderly insomniacs

Benzodiazepines are widely used in the elderly population for the initiation of sleep. However, very frequently, complaints about poor sleep maintenance persist despite benzodiazepine treatment. Melatonin, a hormone produced by the pineal gland at night, is involved in the regulation of the sleep/wake cycle. Melatonin production decreases with age and can also be inhibited by benzodiazepines. We have recently reported on the association between insomnia and impaired melatonin output in the elderly. In the present study we have investigated the efficacy of melatonin replacement therapy in improving sleep in 21 elderly subjects who have been taking benzodiazepines and had low melatonin output. In a randomized, double-blind, crossover designed study the subjects were treated for three weeks with 2 mg per night of controlled-release melatonin and for 3 weeks with placebo, 2 h before desired bedtime with a 1-week washout period between treatment periods. Subjects' sleep was assessed by wrist actigraphy. Melatonin treatment significantly increased sleep efficiency and total sleep time and decreased wake after sleep onset, sleep latency, number of awakenings and fragmental index, as compared to placebo. The results of our study indicate that melatonin replacement therapy can improve sleep quality in the elderly and that the beneficial effects are augmented in the presence of benzodiazepines.

Impaired nocturnal melatonin secretion in non-dipper hypertensive patients

BACKGROUND

Melatonin plays a role in the biologic regulation of circadian rhythms, including sleep. Melatonin has also been shown to modulate vascular smooth muscle tone and to induce hemodynamic effects in humans.

OBJECTIVE

To evaluate whether melatonin plays a role in the circadian rhythm of blood pressure in hypertensive patients.

METHODS

Sixteen elderly patients with essential hypertension were evaluated. Patients were defined as either dippers (DIP, n = 8) or non-dippers (NDIP, n = 8) according to the nocturnal change in the mean arterial pressure (MAP). 6-Sulfatoxymelatonin (6-SMT), the main melatonin metabolite, was determined by enzyme-linked immunosorbent assay (ELISA) in two separate urine collections, one in the daytime and one during the night.

RESULTS

Both groups of DIP and NDIP hypertensives were comparable in regard to age and sex. During the night, the mean arterial pressure decreased by 10.3 +/- 2.2% in the DIP and increased by 7.5 +/- 1.7% in the NDIP group (p < 0.01). Daily 6-SMT was comparable in DIP (3.28 +/- 0.87 microg/12 h) and NDIP (2.31 +/- 0.68 microg/12 h) (p = 0.39). However, while the DIP presented the physiological nocturnal increase in urinary 6-SMT (mean 8.19 +/- 1.68 microg/ 12 h), this surge of melatonin production was missing in NDIP in whom nocturnal urinary 6-SMT concentrations were not significantly different from daily levels (mean 2.56 +/- 0.79 microg/12 h). The nocturnal change in urinary 6-SMT excretion was positively correlated to the nocturnal change in MAP (R = 0.54; p = 0.031).

CONCLUSIONS

NDIP hypertensive patients differ from DIP hypertensives by having an impaired nocturnal melatonin secretion. Thus, melatonin may play a role in the circadian rhythm of blood pressure in hypertensive patients.

Melatonin for treatment of sundowning in elderly persons with dementia - a preliminary study

This pilot study investigated the impact of melatonin administration as a clinical intervention for improving sleep and alleviating sundowning in 11 elderly nursing home residents who suffer from dementia. Melatonin is a hormone produced and secreted by the pineal gland in response to darkness, which plays a major role in the induction and regulation of sleep. Melatonin production decreases with age. Age-related sleep disorders are frequently associated with disruption of circadian cycle rhythms, and sometimes with 'sundowning'. Sundowning refers to the manifestation of agitation and/or confusion in the evening hours. Agitation has been linked to sleep disorders. Analysis revealed a significant decrease in agitated behaviors in all three shifts, and a significant decrease in daytime sleepiness. There was a nonsignificant decrease in latency (time to fall asleep) during the evening shift and no significant changes were reported in night-time sleep ratings. The results of this study are important, because finding ways of decreasing sundowning in elderly persons may improve their well being, alleviate the burden of the caregivers, and even enable caregiving in a less restrictive environment.

Facilitation of benzodiazepine discontinuation by melatonin: a new clinical approach

BACKGROUND

Benzodiazepines are the most frequently used drug for the treatment of insomnia. Prolonged use of benzodiazepine therapy is not recommended. However, many patients, particularly older patients, have difficulties discontinuing therapy. Melatonin, a hormone that is produced at night by the pineal gland, promotes normal sleep in humans and augments sleep induction by benzodiazepine therapy.

OBJECTIVE

To assess whether the administration of melatonin could facilitate the discontinuation of benzodiazepine therapy in patients with insomnia.

METHODS

Thirty-four subjects receiving benzodiazepine therapy were enrolled in the 2-period study. In period 1, patients received (double-blinded) melatonin (2 mg in a controlled-release formulation) or a placebo nightly for 6 weeks. They were encouraged to reduce their benzodiazepine dosage 50% during week 2, 75% during weeks 3 and 4, and to discontinue benzodiazepine therapy completely during weeks 5 and 6. In period 2, melatonin was administered (single-blinded) for 6 weeks to all subjects and attempts to discontinue benzodiazepine therapy were resumed. Benzodiazepine consumption and subjective sleep-quality scores were reported daily by all patients. All subjects were then allowed to continue melatonin therapy and follow-up reassessments were performed 6 months later.

RESULTS

By the end of period 1, 14 of 18 subjects who had received melatonin therapy, but only 4 of 16 in the placebo group, discontinued benzodiazepine therapy (P = .006). Sleep-quality scores were significantly higher in the melatonin therapy group (P = .04). Six additional subjects in the placebo group discontinued benzodiazepine therapy when given melatonin in period 2. The 6-month follow-up assessments revealed that of the 24 patients who discontinued benzodiazepine and received melatonin therapy, 19 maintained good sleep quality.

CONCLUSION

Controlled-release melatonin may effectively facilitate discontinuation of benzodiazepine therapy while maintaining good sleep quality.

Improvement of sleep quality in elderly people by controlled-release melatonin

Melatonin, produced by the pineal gland at night, has a role in regulation of the sleep-wake cycle. Among elderly people, even those who are healthy, the frequency of sleep disorders is high and there is an association with impairment of melatonin production. We investigated the effect of a controlled-release formulation of melatonin on sleep quality in 12 elderly subjects (aged 76 [SD 8] years) who were receiving various medications for chronic illnesses and who complained of insomnia. In all 12 subjects the peak excretion of the main melatonin metabolite 6-sulphatoxymelatonin during the night was lower than normal and/or delayed in comparison with non-insomniac elderly people. In a randomised, double-blind, crossover study the subjects were treated for 3 weeks with 2 mg per night of controlled-release melatonin and for 3 weeks with placebo, with a week's washout period. Sleep quality was objectively monitored by wrist actigraphy. Sleep efficiency was significantly greater after melatonin than after placebo (83 [SE 4] vs 75 [3]%, p < 0.001) and wake time after sleep onset was significantly shorter (49 [14] vs 73 [13] min, p < 0.001). Sleep latency decreased, but not significantly (19 [5] vs 33 [7] min, p = 0.088). Total sleep time was not affected. The only adverse effects reported were two cases of pruritus, one during melatonin and one during placebo treatment; both resolved spontaneously. Melatonin deficiency may have an important role in the high frequency of insomnia among elderly people. Controlled-release melatonin replacement therapy effectively improves sleep quality in this population.

A prospective randomized comparison of an attached silver-impregnated cuff to prevent central venous catheter-associated infection

The VitaCuff catheter, a specialized central venous catheter (CVC) with an attached silver-impregnated cuff, is designed to permit percutaneous placement and prolonged venous access. A prospective randomized study was undertaken comparing the VitaCuff with standard triple lumen catheters to determine if the VitaCuff reduces infection during extended use. All consenting patients underwent percutaneous placement of subclavian lines. By study design, control and VitaCuff catheters could remain in site for up to 7 and 14 days, respectively. Cultures were obtained from the preinsertion skin site, and upon removal, from the skin, hubs, infusates, CVC tip, and cuff. Statistical methods included chi 2, the Student t test, and the log-rank test on Kaplan-Meier estimates. Of 133 patients completing this study, 64 patients (48.1%) underwent VitaCuff placement and 69 patients (51.8%) served as controls. In 124 patients (93.2%), the indication for catheter placement was for perioperative care. Overall, 67 patients (50.4%) required central venous access > 7 days, necessitating > or = 1 additional line in 29 patients (21.8%). The incidence of pneumothorax per patient from the initial central line insertion was 4/104 (3.85%), significantly lower than the 4/29 (13.8%) incidence during secondary catheter placement (P = 0.046). Culture results upon catheter removal demonstrated a reduction in colonization of skin sites and hubs for the VitaCuff patients, but not for catheter tips or infusates. Regardless of the type of catheter used, colonization was dependent upon duration of insertion. The incidence of catheter-related sepsis was 6.8%, and did not differ significantly between the study groups. Multiple CVC insertions increase the incidence of pneumothorax. Because VitaCuff catheters permit extended access up to 14 days without increasing the incidence of sepsis, we recommend their use in patients who require prolonged CVC access.

Preeclampsia and antioxidant nutrients: decreased plasma levels of reduced ascorbic acid, alpha-tocopherol, and beta-carotene in women with preeclampsia

OBJECTIVE

Our purpose was to investigate the plasma levels of three potent antioxidant nutrients in women with preeclampsia.

STUDY DESIGN

Fasting venous blood samples were collected from 30 women with preeclampsia and from 44 women with uncomplicated pregnancies. The criteria for recruitment included age 15 to 35 years, gestational age 28 to 42 weeks, singleton pregnancy, intact membranes, absence of labor contractions, and absence of any other medical complication concurrent with preeclampsia. Reduced ascorbic acid, alpha-tocopherol, and beta-carotene levels were assayed with high-pressure liquid chromatography.

RESULTS

Plasma levels of reduced ascorbic acid were significantly decreased in patients with mild and severe preeclampsia (p < 0.01). Plasma alpha-tocopherol and beta-carotene levels were significantly decreased only in severe preeclampsia compared with controls (p < 0.05 and p < 0.05, respectively).

CONCLUSION

In patients with preeclampsia antioxidant nutrients may be utilized to a greater extent to counteract free radical-mediated cell disturbances, resulting in a reduction in antioxidant plasma levels. Water-soluble antioxidant nutrients may initially be consumed, followed by lipid-soluble antioxidants.

The cadmium toxicity hypothesis of aging: a possible explanation for the zinc deficiency hypothesis of aging

Although cadmium and zinc have similar chemical properties, they affect living organisms diversely: while zinc is an essential element for growth, development and functioning of all living cells, cadmium is a highly toxic material. Cadmium has an extremely long biological half-life and may be considered a cumulative toxin. It has been shown to have sterilizing, teratogenic and carcinogenic effects and most of these effects could be reduced or even prevented by zinc administration. An increase in cadmium concentration with age has been proven in various species and in different tissues and these facts led some investigators to the assumption that cadmium accumulation might play an important role in senescence. Zinc essentiality and the lack of a reliable index of intracellular zinc status, formed the rationale for the zinc deficiency hypothesis of aging. This hypothesis suggests a gradual time related zinc deficiency occurring in each living cell, making zinc less available for its metalloenzymes. The sum of all deleterious effects resulting from the distorted function of different zinc enzymes, is later manifested as aging processes. When cadmium concentration increases, zinc concentration in various tissues decreases. Cadmium may inhibit zinc activities at many stages, interfering with zinc absorption, distribution to different tissues and transport into cells or into several intracellular structures. Therefore, it is reasonable to assume that a slowly developing cadmium toxicity may result in a gradual time related zinc deficiency.

Platinum chemotherapy during pregnancy for serous cystadenocarcinoma of the ovary

Ovarian carcinoma in pregnancy remains a rare event. Although concern regarding the gestation complicates therapy, platinum drug-based combination chemotherapy is often deemed warranted in such cases. We report the antepartum use of cisplatin, followed by carboplatin, for an ovarian serous cystadenocarcinoma. During this treatment, serial sonographic assessment of fetal morphometric parameters and biophysical profiles with fetal heart rate monitoring were performed to document fetal well being. Platinum-DNA adducts were measured in maternal blood, placenta, fetal amniotic cells, and cord blood. This report represents an attempt to define platinum drug transfer in utero and fetal growth and development during therapy and to document the first use of carboplatin in pregnancy.

A computer model of pancreatic islet glycolysis

We have modeled an experiment with perifused pancreatic islet cells using our BIOSSIM language. The experiment and the resulting model are concerned with glucose uptake and glycolysis by the beta-cells of pancreatic islets. Although glycolysis appears to be involved in insulin release, we do not have enough information to represent insulin release in detail. The rapid entry of glucose into the beta-cell is promoted by a carrier having a very high tissue capacity. Phosphorylation of glucose by the low affinity enzyme glucokinase appears to be limiting for glycolysis. The effects of several hexose diphosphate activators of phosphofructokinase are modeled. Model behavior is described. The kinetic parameters of the enzyme submodels are given. Because of the difficulties of preparing large amounts of experimental material, information on pancreatic islet metabolism is limited. This model is a plausible explanation of the experimental results. Recent work on the genetically engineered glucose transporter and glucokinase is discussed.

An artificial-intelligence technique for qualitatively deriving enzyme kinetic mechanisms from initial-velocity measurements and its application to hexokinase

We have developed a computer method based on artificial-intelligence techniques for qualitatively analysing steady-state initial-velocity enzyme kinetic data. We have applied our system to experiments on hexokinase from a variety of sources: yeast, ascites and muscle. Our system accepts qualitative stylized descriptions of experimental data, infers constraints from the observed data behaviour and then compares the experimentally inferred constraints with corresponding theoretical model-based constraints. It is desirable to have large data sets which include the results of a variety of experiments. Human intervention is needed to interpret non-kinetic information, differences in conditions, etc. Different strategies were used by the several experimenters whose data was studied to formulate mechanisms for their enzyme preparations, including different methods (product inhibitors or alternate substrates), different experimental protocols (monitoring enzyme activity differently), or different experimental conditions (temperature, pH or ionic strength). The different ordered and rapid-equilibrium mechanisms proposed by these experimenters were generally consistent with their data. On comparing the constraints derived from the several experimental data sets, they are found to be in much less disagreement than the mechanisms published, and some of the disagreement can be ascribed to different experimental conditions (especially ionic strength).

Constraint matching as a means of designing biochemical experiments in multi-enzyme systems

A method of qualitative analysis by constraint matching, where expectations derived from theory or from data bases are systematically compared against experimental findings, is described. This was originally developed as an artificial intelligence technique to analyze enzyme kinetic mechanism determinations. It is shown to have been used (without computer involvement) in designing experiments involving a few enzymes, and is suggested as a useful experimental design tool. The experiments in question validate the behavior of insulinoma extracts as models for pancreatic islet glycolysis, which conform to the expectations from the relevant enzyme literature. Possible generalization to other areas of biological research is suggested.

Liver cirrhosis and hepatocellular carcinoma after prolonged exposure to TNT: causal relationship or mere coincidence?

Macronodular liver cirrhosis and hepatocellular carcinoma were found in a 61-year-old male who had been exposed for 35 years to Trinitrotoluene (TNT). The question whether TNT had induced these pathological processes is raised.

Theory formation in postulating enzyme kinetic mechanisms: reasoning with constraints

This paper reports on a prototype system for modeling and analyzing the expert reasoning involved in postulating enzyme kinetic mechanisms. It involves data-driven, theory-driven, and analogical components of reasoning within a generate-and-test cycle. Its central component is a set of domain-specific "filters" for matching experimentally and theoretically derived constraints. The input to the system consists of an abstracted qualitative description of an experiment and prior knowledge reported in the literature. Its output shows how the results match those expected for a set of postulated reaction mechanism models and also provides a trace of which features do or do not match each of the candidate topological models. Results, constraints, and models are all analyzed and compared to those from other, similar experiments. We deduced rules for interpreting the qualitative features of enzyme kinetic experiments from natural language descriptions in the literature and verified that the rules were correct by predicting the results for typical mechanisms. We obtained the correct behavior for all 37 states of a complex enzyme mechanism involving three substrates and three products. We tested our system on data from several published reports dealing with the enzyme hexokinase and obtained detailed listings of the differences in conclusions and interpretation reported in several journal articles. This system, which provides qualitative representations of enzyme kinetic results, should facilitate further experimentation on theory formation in enzyme kinetics and lead to more efficient experimental designs.

Pancreatic islet discrimination of hexose anomers. II. Transient computer simulation

We have previously modeled pancreatic islet glycolysis under idealized steady-state conditions where the input is a pure hexose anomer and there is no mutarotation and reproduced the known preference for the alpha-anomers of glucose and mannose as substrates. This model is here extended to simulate real experiments, where the hexoses mutarotate and measurements may be taken over time. The behavior of our model system agrees with available experimental data. The hexose diphosphate activators of phosphofructokinase, whose effect was seen as not important in the preceding steady-state analysis, are found here to have a modest (approximately 10-15%) effect on its flux. The previous conclusion that the anomeric preference of the glycolytic pathway follows from that of glucokinase continues to hold in the real experimental situation.

Pancreatic islet discrimination of hexose anomers. I. Steady-state computer simulation

Pancreatic islets detect glucose level by phosphorylating it and converting the glycolytic rate to a signal to secrete insulin. Insulin secretion is greater from the alpha- than from the beta-anomer when the D-glucose level is below 22 mM. D-mannose behaves similarly but at nearly twofold higher concentrations. Two explanations have been proposed: 1) glucokinase, which has the same anomeric preference, is the principal hexose phosphorylating enzyme and limits glycolytic rate. 2) Phosphofructokinase limits glycolysis and hexokinase is the principal enzyme phosphorylating hexose; hexosediphosphate activators of phosphofructokinase are more readily synthesized from alpha-anomers of hexose phosphates. We have simulated both alternatives with a detailed anomerically specific model of the hexose-metabolizing glycolytic enzymes. The pathway preference for alpha-anomer of both hexoses was adequately reproduced with anomerically active limiting glucokinase. The other mechanism did not reproduce the observed pathway preference.

Altered therapeutic range for quinidine after myocardial infarction and cardiac surgery

Although most assays for measuring drug levels in serum determine the total concentration, effects from a drug are determined better by measuring the concentration of unbound (free) drug in serum. When the free fraction of a drug is constant, the total drug concentration may act as a good guide in predicting drug activity. However, if the free fraction is altered from normal, the serum concentration of the total drug may be misinterpreted. Quinidine has a high binding affinity for alpha-1-acid glycoprotein. We present the case of a woman who had a myocardial infarction; after cardiac surgery, she was found to have high concentrations of alpha-1-acid glycoprotein (228 mg/dL) and a low free fraction of quinidine (0.032). At that time the patient had a total concentration of quinidine of 33.9 mumol/L (11 micrograms/mL) but showed no signs or symptoms of toxicity because the concentration of free quinidine was not high. Physicians should be aware of the limitations of assays in determining the unbound concentration of drugs in serum. This awareness is particularly crucial with drugs that bind well to serum proteins, especially when pathologic conditions change the extent of binding.

Modeling and artificial intelligence approaches to enzyme systems

Modeling is a means of formulating and testing complex hypotheses. Useful modeling is now possible with biological laboratory microcomputers with which experimenters feel comfortable. Artificial intelligence (AI) is sufficiently similar to modeling that AI techniques, now becoming usable on microcomputers, are applicable to modeling. Microcomputer and AI applications to physiological system studies with multienzyme models and with kinetic models of isolated enzymes are described. Using an IBM PC microcomputer, we have been able to fit kinetic enzyme models; to extend this process to design kinetic experiments by determining the optimal conditions; and to construct an enzyme (hexokinase) kinetics data base. We have also used a PC to do most of the constructing of complex multienzyme models, initially with small simple BASIC programs; alternative methods with standard spreadsheet or data base programs have been defined. Formulating and solving differential equations in appropriate representational languages, and sensitivity analysis, are soon likely to be feasible with PCs. Much of the modeling process can be stated in terms of AI expert systems, using sets of rules for fitting and evaluating models and designing further experiments. AI techniques also permit critiquing and evaluating the data, experiments, and hypotheses being modeled, and can be extended to supervise the calculations involved.

Kinetic properties of hexokinase as assembled with a microcomputer data base

We have constructed a relational data base containing the kinetic properties of the isoenzymes of hexokinase using the Knowledgeman data-base program on an IBM PC microcomputer. The natural subunit of this data base is the refereed publication, 165 of which were included. Reported values for the Mr (approx. 97,000) are in good agreement, but this agreement becomes progressively worse as one examines the Km values for glucose and ATP and the Ki for glucose 6-phosphate, where the reported values are spread over three orders of magnitude. Some quantities are very thinly or unreliably determined. Experimental conditions, especially free Mg2+ concentration, are rarely close to physiological. Reasons for the spread or uncertainty of numbers, and the distinctions that can be made between isoenzymes despite this spread, are discussed.

Magnesium in cardiac energy metabolism

Free intracellular magnesium ion, which influences many metabolic processes, is the subject of ongoing research. Its concentration has been difficult to measure because the available methods, including dye injection, microelectrodes, and nuclear magnetic resonance measurements, are invasive or indirect. Concentrations ranging from 0.1 mM in frog muscle to 6 mM in barnacle muscle have been reported. We describe recent experimental evidence regarding the concentration of free intracellular magnesium and consider the limitations of these methods. A substantial body of evidence, including our models of cardiac energy metabolism and its magnesium-related processes, indicates that intracellular concentrations of free magnesium are low (ca. 0.4 mM) and vary with time and conditions.