Inappropriateness of Medication Prescriptions to Elderly Patients in the Primary Care Setting: A Systematic Review

Posted on August 24, 2012 by Maurice Preter MD

This interesting meta-analysis was just published (notably, in a very reputable open-access, advertisement-free journal). 20% seems a very conservative estimate…
The PDF is here:

Here is the abstract:

RESEARCH ARTICLE
Inappropriateness of Medication Prescriptions to Elderly Patients in the Primary Care Setting: A Systematic Review

Dedan Opondo1*, Saied Eslami1, Stefan Visscher2, Sophia E. de Rooij3, Robert Verheij2, Joke C. Korevaar2, Ameen Abu-Hanna1
1 Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, 2 Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands, 3 Department of Geriatrics, Academic Medical Center, University of Amsterdam, The Netherlands
Abstract Top
Background
Inappropriate medication prescription is a common cause of preventable adverse drug events among elderly persons in the primary care setting.

Objective
The aim of this systematic review is to quantify the extent of inappropriate prescription to elderly persons in the primary care setting.

Methods
We systematically searched Ovid-Medline and Ovid-EMBASE from 1950 and 1980 respectively to March 2012. Two independent reviewers screened and selected primary studies published in English that measured (in)appropriate medication prescription among elderly persons (>65 years) in the primary care setting. We extracted data sources, instruments for assessing medication prescription appropriateness, and the rate of inappropriate medication prescriptions. We grouped the reported individual medications according to the Anatomical Therapeutic and Chemical (ATC) classification and compared the median rate of inappropriate medication prescription and its range within each therapeutic class.

Results
We included 19 studies, 14 of which used the Beers criteria as the instrument for assessing appropriateness of prescriptions. The median rate of inappropriate medication prescriptions (IMP) was 20.5% [IQR 18.1 to 25.6%.]. Medications with largest median rate of inappropriate medication prescriptions were propoxyphene 4.52(0.10–23.30)%, doxazosin 3.96 (0.32 15.70)%, diphenhydramine 3.30(0.02–4.40)% and amitriptiline 3.20 (0.05–20.5)% in a decreasing order of IMP rate. Available studies described unequal sets of medications and different measurement tools to estimate the overall prevalence of inappropriate prescription.

Conclusions
Approximately one in five prescriptions to elderly persons in primary care is inappropropriate despite the attention that has been directed to quality of prescription. Diphenhydramine and amitriptiline are the most common inappropriately prescribed medications with high risk adverse events while propoxyphene and doxazoxin are the most commonly prescribed medications with low risk adverse events. These medications are good candidates for being targeted for improvement e.g. by computerized clinical decision support.

Citation: Opondo D, Eslami S, Visscher S, de Rooij SE, Verheij R, et al. (2012) Inappropriateness of Medication Prescriptions to Elderly Patients in the Primary Care Setting: A Systematic Review. PLoS ONE 7(8): e43617. doi:10.1371/journal.pone.0043617

Editor: Colin Simpson, The University of Edinburgh, United Kingdom

Received: January 3, 2012; Accepted: July 23, 2012; Published: August 22, 2012

Copyright: © 2012 Opondo et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: These authors have no support or funding to report.

Competing interests: The authors have declared that no competing interests exist.

* E-mail: d.o.opondo@amc.uva.nl

Posted in Aging, Forensic Neuropsychiatry, Health, News, Psychiatry/Neurology | Tagged , |

SSRIs should be considered in the list of medications that are risk factors for osteoporotic fractures.

Posted on August 21, 2012 by Maurice Preter MD
Not really news but still an important pharmacovigilance paper.
As has been correctly pointed out, relevant to the changing informed consent & decision making landscape.
More on the subject matter at http://www.ncbi.nlm.nih.gov/pubmed/17592097
Bone. 2012 Sep;51(3):606-13. Epub 2012 May 30.

Antidepressant medications and osteoporosis.

Source

Division of Bone Diseases, Department of Medical Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.

Abstract

Use of antidepressant medications that act on the serotonin system has been linked to detrimental impacts on bone mineral density (BMD), and to osteoporosis. This article reviews current evidence for such effects, and identifies themes for future research. Serotonin receptors are found in all major types of bone cell (osteoblasts, osteocytes, and osteoclasts), indicating an important role of the neuroendocrine system in bone. Observational studies indicate a complex relationship between depression, antidepressants, and fracture. First, the presence of depression itself increases fracture risk, in relation with decreased BMD and an increase in falls. A range of aspects of depression may operate, including behavioral factors (e.g., smoking and nutrition), biological changes, and confounders (e.g., comorbidities and concomitant medications). A substantial proportion of depressed patients receive antidepressants, mostly selective serotonin reuptake inhibitors (SSRIs). Some of these have been linked to decreased BMD (SSRIs) and increased fracture risk (SSRIs and tricyclic agents). Current use of SSRIs and tricyclics increases fracture risk by as much as twofold versus nonusers, even after adjustment for potential confounders. While there is a dose-response relationship for SSRIs, the effect does not appear to be homogeneous across the whole class of drugs and may be linked to affinity for the serotonin transporter system. The increase in risk is the greatest in the early stages of treatment, with a dramatic increase after initiation, reaching a peak within 1month for tricyclics and 8months for SSRIs. Treatment-associated increased risk diminishes towards baseline in the year following discontinuation. The body of evidence suggests that SSRIs should be considered in the list of medications that are risk factors for osteoporotic fractures.

Copyright © 2012 Elsevier Inc. All rights reserved.

PMID:
22659406
[PubMed – in process]

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Posted in Aging, Forensic Neuropsychiatry, Health, metabolic, News, Psychiatry/Neurology | Tagged , |

From the Blackburn lab: Socioeconomic status and cell aging in children.

Posted on August 12, 2012 by Maurice Preter MD

I am studying telomerase-environment interactions. Fascinating, as they say. Not news, but –  poverty and lack of education kills (faster), literally. Link http://biochemistry.ucsf.edu/labs/blackburn/index.php?option=com_content&view=article&id=12&Itemid=8

Here is the abstract:

Soc Sci Med. 2012 Jun;74(12):1948-51. Epub 2012 Mar 17.
Socioeconomic status and cell aging in children.
Needham BL, Fernandez JR, Lin J, Epel ES, Blackburn EH.
Source
Department of Sociology, University of Alabama at Birmingham, 1530 3rd Ave. S., HHB 460C, Birmingham, AL 35294, USA. bneedham@uab.edu
Abstract
Theory suggests that chronic stress associated with disadvantaged social status may lead to acceleration in the rate of decline in physiological functioning. The purpose of this study is to examine the association between parental socioeconomic status (SES) and leukocyte telomere length (LTL), a marker of cell aging, in children. We examined SES and LTL in 70 white and black US children aged 7-13 who participated in the community-based AMERICO (Admixture Mapping for Ethnic and Racial Insulin Complex Outcomes) study. LTL was assessed using the polymerase chain reaction (PCR) method. Parental education was positively associated with child LTL, net of controls for sex, age, race/ethnicity, and family income. Compared to children with at least one college-educated parent, children whose parents never attended college had telomeres shorter by 1,178 base pairs, which is roughly equivalent to 6 years of additional aging. Socioeconomic disparities in cell aging are evident in early life, long before the onset of age-related diseases.
Copyright © 2012 Elsevier Ltd. All rights reserved.
PMID: 22472277 [PubMed – in process]
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Posted in Aging, development, epigenetics, Forensic Neuropsychiatry, Health, News | Tagged , , , |

Traumatic loss, adult separation anxiety and childhood asthma

Posted on August 4, 2012 by Maurice Preter MD

Prenatal Stress and Risk of Asthma Hospitalization in the Offspring: A Swedish Population-Based Study

  1. Ali S. Khashan, PhD,
  2. Susanne Wicks, PhD,
  3. Christina Dalman, MD, PhD,
  4. Tine B. Henriksen, PhD,
  5. Jiong Li, PhD,
  6. Preben B. Mortensen, DMSc and
  7. Louise C. Kenny, MRCOG, PhD

+ Author Affiliations


  1. From the Anu Research Centre (A.S.K., L.C.K.), Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Cork, Ireland; Division of Public Health Epidemiology (S.W., C.D.), Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden; and Perinatal Epidemiology Research Unit (T.B.H.), Department of Paediatrics, Aarhus University Hospital, Skejby; and The Danish Epidemiology Science Centre (J.L.), Department of Epidemiology, Institute of Public Health, and National Centre for Register-based Research (P.B.M.), University of Aarhus, Denmark.
  1. Address correspondence and reprint requests to Ali S. Khashan, PhD, Anu Research Center, Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Cork, Ireland. E-mail: a.khashan@ucc.ie

Abstract

Objective Recent research suggested that maternal stress and anxiety increase the risk of asthma and eczema in the offspring. In this study, we aimed to study whether maternal exposure to death of a spouse or a child is associated with risk of asthma hospitalization in the offspring using a very large population-based cohort.

Methods In a cohort of 3.2 million births in Sweden between January 1, 1973, and December 31, 2004, mothers were considered exposed if their spouse or child died up to 6 months before or during pregnancy. Offspring were followed up from birth to their death, migration, first hospitalization with asthma, or December 31, 2006, whichever came first; hospital admissions were identified by linkage of several national Swedish registers. Log-linear Poisson regression was used for data analysis.

Results Overall, the risk of offspring asthma was increased with any prenatal exposure to bereavement in any exposure period (adjusted relative risk [RR] = 1.20 [95% confidence interval {CI} = 1.03–1.39]). The risk was higher when the exposure period was restricted to pregnancy only (adjusted RR = 1.43 [95% CI = 1.06–1.92]). Furthermore, the risk of asthma was increased in relation to death of a spouse during pregnancy (adjusted RR = 1.59 [95% CI = 1.10–2.30]).

Conclusions These findings suggest that prenatal exposure to severe life events increases the risk of hospitalization for asthma in the offspring. Fetal programming may be a plausible explanation for the association.

Key words

Posted in Affective Neuroscience, development, epigenetics, Forensic Neuropsychiatry, Health | Tagged , , , , , , |

Unpredictable chronic mild stress and endothelial damage

Posted on August 4, 2012 by Maurice Preter MD

Just like “mild” traumatic brain injury, mild stress is relative.

___________________________________

Unpredictable Chronic Mild Stress Promotes Atherosclerosis in High Cholesterol–Fed Rabbits

  1. Xiao-Ting Lu, PhD,
  2. Yun-Fang Liu, PhD,
  3. Lei Zhang, PhD,
  4. Rui-Xue Yang, PhD,
  5. Xiao-Qiong Liu, PhD,
  6. Fang-Fang Yan, PhD,
  7. Ying-Bin Wang, PhD,
  8. Wen-Wu Bai, PhD,
  9. Yu-Xia Zhao, MD and
  10. Fan Jiang, PhD

+ Author Affiliations


  1. From the Key Laboratory of Cardiovascular Remodeling and Function Research (Chinese Ministry of Education and Chinese Ministry of Health) (X.-T.L., L.Z., F.J.), Departments of Traditional Chinese Medicine (X.-T.L., X.-Q.L., F.-F.Y., Y.-B.W., W.-W.B., Y.-X.Z.) and Electrocardiogram Cardiology (R.-X.Y.), Qilu Hospital, and Department of Diagnosis (Y.-F.L.), Medical School, Shandong University, Jinan, Shandong Province, People’s Republic of China.
  1. Address correspondence and reprint requests to Yu-Xia Zhao, MD, or Fan Jiang, PhD, Shandong University Qilu Hospital, 107, Wen Hua Xi Rd, Jinan, Shandong Province, 250012, People’s Republic of China. E-mail: zhchsir@163.com; or fjiang@sdu.edu.cn

Abstract

Objectives Chronic psychological stress is associated with an increased risk of atherosclerosis in humans. Experimental studies using various stress models have yielded controversial results. This study investigated the effects of unpredictable chronic mild stress (UCMS) on atherogenesis in New Zealand white rabbits.

Methods Rabbits were fed with a cholesterol-enriched (1%) diet for 4 to 16 weeks, with or without concomitant UCMS treatment. Atherosclerosis was assessed in the abdominal aorta by serial sectioning and morphological analysis. Expressions of inflammatory factors were measured with immunohistochemistry and quantitative polymerase chain reaction. Serum nitrate/nitrite levels were determined with Griess assay, and corticosterone and inflammatory markers were determined using enzyme-linked immunosorbent assay.

Results High-cholesterol feeding resulted in hypercholesterolemia and formation of atherosclerotic plaques in the aorta. UCMS exposure significantly increased the plaque size (p = .003) and decreased the plaque stability (decreased the contents of collagen and smooth muscle and increased the amount of macrophage and matrix metalloproteinases). The proatherogenic effects of UCMS were unrelated to changes in serum cholesterol level but accompanied by increased blood pressure (p < .001) and vascular inflammation (up-regulation of tumor necrosis factor α, C-reactive protein, and monocyte chemoattractant protein 1, all p values < .01). Serum concentrations of nitrate/nitrite were lower in UCMS-treated animals (p = .01). Vessels from UCMS-treated animals exhibited augmented phosphorylation of p38 and c-Jun N-terminal kinase and activation of nuclear factor κB.

Conclusions Chronic psychological stress may contribute to the development of atherosclerosis by enhancing vascular inflammation and decreasing endothelial nitric oxide bioavailability.

Key words

Posted in Affective Neuroscience, epigenetics, Forensic Neuropsychiatry, Health, Psychiatry/Neurology | Tagged , , , , , |