Pay for performance associated with increased volume of medication reviews but not with less inappropriate use of medications among the elderly - an observational study.

OBJECTIVE: A pay for performance programme was introduced in 2009 by a Swedish county with 1.6 million inhabitants. A process measure with payment linked to coding for medication reviews among the elderly was adopted. We assessed the association with inappropriate medication for five years after baseline. DESIGN AND SETTING: Observational study that compared medication for elderly patients enrolled at primary care units that coded for a high or low volume of medication reviews. PATIENTS: 144,222 individuals at 196 primary care centres, age 75 or older. MAIN OUTCOME MEASURES: Percentage of patients receiving inappropriate drugs or polypharmacy during five years at primary care units with various levels of reported medication reviews. RESULTS: The proportion of patients with a registered medication review had increased from 3.2% to 44.1% after five years. The high-coding units performed better for most indicators but had already done so at baseline. Primary care units with the lowest payment for coding for medication reviews improved just as well in terms of inappropriate drugs as units with the highest payment - from 13.0 to 8.5%, compared to 11.6 to 7.4% and from 13.6 to 7.2% vs 11.8 to 6.5% for polypharmacy. CONCLUSIONS: Payment linked to coding for medication reviews was associated with an increase in the percentage of patients for whom a medication review had been registered. However, the impact of payment on quality improvement is uncertain, given that units with the lowest payment for medication reviews improved equally well as units with the highest payment.

Antidepressants and mortality risk in a dementia cohort: data from SveDem, the Swedish Dementia Registry.

BACKGROUND: The association between mortality risk and use of antidepressants in people with dementia is unknown. OBJECTIVE: To describe the use of antidepressants in people with different dementia diagnoses and to explore mortality risk associated with use of antidepressants 3 years before a dementia diagnosis. METHODS: Study population included 20 050 memory clinic patients from the Swedish Dementia Registry (SveDem) diagnosed with incident dementia. Data on antidepressants dispensed at the time of dementia diagnosis and during 3-year period before dementia diagnosis were obtained from the Swedish Prescribed Drug Register. Cox regression models were used. RESULTS: During a median follow-up of 2 years from dementia diagnosis, 25.8% of dementia patients died. A quarter (25.0%) of patients were on antidepressants at the time of dementia diagnosis, while 21.6% used antidepressants at some point during a 3-year period before a dementia diagnosis. Use of antidepressant treatment for 3 consecutive years before a dementia diagnosis was associated with a lower mortality risk for all dementia disorders and in Alzheimer's disease. CONCLUSION: Antidepressant treatment is common among patients with dementia. Use of antidepressants during prodromal stages may reduce mortality in dementia and specifically in Alzheimer's disease.

Cognitive deficits in unipolar old-age depression: a population-based study.

BACKGROUND: There is substantial variability in the degree of cognitive impairment among older depressed persons. Inconsistencies in previous findings may be due to differences in clinical and demographic characteristics across study samples. We assessed the influence of unipolar depression and severity of depression on cognitive performance in a population-based sample of elderly persons aged ⩾60 years. METHOD: Eighty-nine persons fulfilled ICD-10 criteria for unipolar depression (mild, n = 48; moderate, n = 38; severe, n = 3) after thorough screening for dementia (DSM-IV criteria), psychiatric co-morbidities and antidepressant pharmacotherapy. Participants (n = 2486) were administered an extensive cognitive test battery. RESULTS: Moderate/severe unipolar depression was associated with poorer performance on tasks assessing processing speed, attention, executive function, verbal fluency, episodic memory and vocabulary. Mild depression was associated with poorer performance in processing speed, and few differences between mild and moderate/severe depression were observed. No association between depression and short-term memory, general knowledge or spatial ability was observed. Increasing age did not exacerbate the depression-related cognitive deficits, and the deficits remained largely unchanged after excluding persons in a preclinical phase of dementia. Furthermore, depression-related cognitive deficits were not associated with other pharmacological treatments that may affect cognitive performance. CONCLUSIONS: Cognitive deficits in unipolar old-age depression involve a range of domains and the cognitive deficits seem to follow the spectrum of depression severity. The finding that mild depression was also associated with poorer cognitive functioning underscores the importance of detecting mild depression in elderly persons.

Undertreatment of osteoporosis in persons with dementia? A population-based study.

UNLABELLED: In this population-based study of more than 2,600 elderly, people with dementia received less preventive treatment for osteoporosis compared to people without dementia, although osteoporotic fractures were more common in patients with dementia. Thus, our results indicate an undertreatment of osteoporosis in dementia. INTRODUCTION: This study compares the use of osteoporosis drugs in elderly with and without dementia, taking into account osteoporotic fractures and type of housing. METHODS: We analyzed data from the baseline examination (2001-2004) of The Swedish National Study on Aging and Care- Kungsholmen (SNAC-K), Stockholm, Sweden. Participants were aged ≥ 66 years (n = 2610). We analysed the use of bisphosphonates, raloxifene, and calcium/vitamin D combinations in relation to clinically based dementia diagnosis. Information about osteoporotic fractures during the previous 4 years was obtained from the Swedish National Patient Register. We used logistic regression to analyze the association between dementia status and use of osteoporosis drugs. RESULTS: Osteoporosis drugs (mainly calcium/vitamin D combinations) were used by 5% of the persons with dementia and 12% of the persons without dementia. Furthermore, 25% of the persons with dementia and 7% of the persons without dementia had had at least one osteoporotic fracture during the past 4 years. After controlling for age, sex, osteoporotic fractures, and type of housing (own home or institution), persons with dementia were less likely to use osteoporosis drugs than persons without dementia (OR = 0.34; 95% CI, 0.19-0.59). CONCLUSIONS: Our results indicate an undertreatment of osteoporosis in persons with dementia, although osteoporotic fractures are common among these patients.

Trends in polypharmacy and potential drug-drug interactions across educational groups in elderly patients in Sweden for the period 1992 - 2002.

OBJECTIVE: This study investigates the changes in drug use, polypharmacy and potential drug-drug interactions (DDIs) between educational groups of Swedish elderly over a 10-year period from 1992 - 2002. METHODS: We used data from SWEOLD I (n = 512) from 1992 and SWEOLD II from 2002 (n = 561), which are nationally representative surveys of the elderly population in Sweden aged 77 years and older. Both community-based and institutionalized persons were included. Information on drug use was based on personal interviews and all drugs used in the two weeks prior to the studies were recorded. The three outcomes under study were drug use, polypharmacy (concurrent use of five or more drugs), and potential DDIs. RESULTS: In the SWEOLD data from 1992 - 2002, the mean number of drugs used per person increased from 2.5 - 4.4. Overall, 81% of the study participants were drug users in 1992 as compared to 88% in 2002. The prevalence of polypharmacy increased 3-fold (from 18% in 1992 to 42% in 2002) after controlling for age and gender. In both SWEOLD surveys, the less educated reported polypharmacy more often (19% in 1992 and 46% in 2002) than the higher educated (12% in 1992 and 36% in 2002). Potential DDIs also increased, both among the less educated (14% in 1992 to 26% in 2002) and the higher educated (18% in 1992 to 24% in 2002). The most pronounced changes in the consumption of specific drug groups were observed in antithrombotic agents, beta-blocking agents, ACE inhibitors, and vitamin B12 and folic acid. In general, the use of most therapeutic classes increased more among the well educated compared to less educated men between 1992 and 2002, whereas the opposite relationship prevailed among women. CONCLUSION: This study indicates that the use of drugs, polypharmacy and potential DDIs have increased during 1992 to 2002 among the elderly. These changes were most prominent among the less educated women. Polypharmacy and potential DDIs represent potential health hazards for the elderly. Therefore, the trends of increasing polypharmacy and drug-drug interactions deserve attention and the mechanisms behind should be investigated further.

Receptor-G-protein signalling in Alzheimer's disease.

Based on radioligand binding studies, it has long been assumed that the neurochemical pathology of Alzheimer's disease (AD) does not involve widespread changes in post-synaptic neurotransmitter function. However, more recent studies suggest that receptor function in AD may be compromised due to disrupted post-receptor signal transduction, in particular that mediated by the G-protein regulated phosphoinositide hydrolysis and adenylate cyclase (AC) pathways. The phosphoinositide hydrolysis pathway has been shown to be altered at a number of levels in AD post-mortem brains, including impaired agonist and G-protein regulation of phospholipase C, decreased protein kinase C (PKC) levels and activity, and a reduced number of receptor sites for the second messenger, Ins(1,4,5)P3. Of these, loss of Ins(1,4,5)P3 receptors and PKC in the entorhinal cortex and hippocampus correlates with AD-related neurofibrillary changes, as staged according to Braak's protocol. Disregulation of the phosphoinositide hydrolysis pathway may therefore have consequences for the progression of AD pathology. In contrast to the extensive pattern of disruption seen with the phosphoinositide hydrolysis pathway, changes to AC signalling in AD appear more circumscribed. Disruptions include a lesion at the level of Gs-protein stimulation of AC and, at least in the hippocampus, reduced enzyme activities in response to forskolin stimulation. Of these, the latter change has been shown to precede neurofibrillary changes. Apart from a loss of calcium/calmodulin sensitive AC isoforms, other components of this signalling pathway, including G-protein levels, Gi-protein mediated inhibition and protein kinase A levels and activity, remain relatively preserved in the disorder.

Dysfunctional intracellular calcium homoeostasis: a central cause of neurodegeneration in Alzheimer's disease.

The clinical symptoms of all forms of Alzheimer's disease (AD) result from a slowly progressive neurodegeneration that is associated with the excessive deposition of beta-amyloid (A beta) in plaques and in the cerebrovasculature, and the formation of intraneuronal neurofibrillary tangles, which are composed primarily of abnormally hyperphosphorylated tau protein. The sequence of cellular events that cause this pathology and neurodegeneration is unknown. It is, however, most probably linked to neuronal signal transduction systems that become misregulated in the brains of certain individuals, causing excessive A beta to be formed and/or deposited, tau to become aggregated and hyperphosphorylated and neurons to degenerate. We hypothesize that a progressive alteration in the ability of neurons to regulate intracellular calcium, particularly at the level of the endoplasmic reticulum, is a crucial signal transduction event that is linked strongly to the initiation and development of AD pathology. In this chapter we will discuss the key findings that lend support to this hypothesis.

Occurrence and progression of dementia in a community population aged 75 years and older: relationship of antihypertensive medication use.

OBJECTIVE: To examine whether antihypertensive medication use can affect the occurrence and progression of dementia. SUBJECTS AND METHODS: In a community cohort of 1810 persons aged 75 years and older, 225 prevalent cases of dementia were detected. Among the 1301 persons without dementia, 224 incident cases of dementia were identified during an average period of 3 years. Among the 225 prevalent cases of dementia, 79 were suitable for the analysis of cognitive decline. Information on drug use was collected for the 2 weeks preceding the baseline interview. RESULTS: Subjects taking antihypertensive medication (n = 651, 83.9% of whom took diuretics) had a lower prevalence of dementia than those not taking antihypertensive medication (P<.001). Subjects without dementia who were taking antihypertensive medication at baseline (n = 584) had a reduced incidence of dementia (adjusted relative risk, 0.7; 95% confidence interval, 0.6-1.0; P = .03). Furthermore, subjects taking diuretics (n = 484) had an adjusted relative risk of 0.7 (95% confidence interval, 0.5-1.0; P = .02) for all dementia, and subjects taking diuretic monotherapy (n = 345) had an adjusted relative risk of 0.6 (95% confidence interval, 0.4-0.9; P = .006). The use of other antihypertensive medication (calcium antagonists or beta-blockers), however, was related to a reduced risk of Alzheimer disease (adjusted relative risk, 0.6; 95% confidence interval, 0.3-1.2) only in the subpopulation with a higher baseline blood pressure (n = 458). Patients with dementia at baseline who were not taking diuretics had a 2-fold faster rate of decline in the score on the Mini-Mental State Examination than those taking diuretics. CONCLUSION: The use of diuretics may protect against dementia in elderly persons.

Vitamin B(12) and folate in relation to the development of Alzheimer's disease.

OBJECTIVE: To explore the associations of low serum levels of vitamin B(12) and folate with AD occurrence. METHODS: A population-based longitudinal study in Sweden, the Kungsholmen PROJECT: A random sample of 370 nondemented persons, aged 75 years and older and not treated with B(12) and folate, was followed for 3 years to detect incident AD cases. Two cut-off points were used to define low levels of vitamin B(12) (< or =150 and < or =250 pmol/L) and folate (< or =10 and < or =12 nmol/L), and all analyses were performed using both definitions. AD and other types of dementia were diagnosed by specialists according to DSM-III-R criteria. RESULTS: When using B(12) < or =150 pmol/L and folate < or =10 nmol/L to define low levels, compared with people with normal levels of both vitamins, subjects with low levels of B(12) or folate had twice higher risks of developing AD (relative risk [RR] = 2.1, 95% CI = 1.2 to 3.5). These associations were even stronger in subjects with good baseline cognition (RR = 3.1, 95% CI = 1.1 to 8.4). Similar relative risks of AD were found in subjects with low levels of B(12) or folate and among those with both vitamins at low levels. A comparable pattern was detected when low vitamin levels were defined as B(12) < or =250 pmol/L and folate < or =12 nmol/L. CONCLUSIONS: This study suggests that vitamin B(12) and folate may be involved in the development of AD. A clear association was detected only when both vitamins were taken into account, especially among the cognitively intact subjects. No interaction was found between the two vitamins. Monitoring serum B(12) and folate concentration in the elderly may be relevant for prevention of AD.

Regional differences in the effect of guanine nucleotides on agonist and antagonist binding to adenosine A1-receptors in rat brain, as revealed by autoradiography.

The effect of increasing doses of GTP on agonist and antagonist binding to adenosine A1-receptors in different regions of rat brain was studied by autoradiography. A high concentration of GTP (100 microM) practically eliminated the binding of the agonist [3H]N6-cyclohexyladenosine in all regions. However, there were regional differences in the effects of low concentrations of GTP (0.1-10 microM). In some regions, for example the hippocampus, all concentrations of GTP decreased [3H]N6-cyclohexyladenosine binding, by decreasing the Bmax. In other structures, e.g. the superior colliculus, there was a biphasic response to GTP. Concentrations of 0.1-3 microM increased agonist binding, apparently due to a decrease in KD, whereas higher concentrations also decreased binding in these regions. The effects of GTP were mimicked by the stable GTP analogue guanosine-5'-O-(3-thiotriphosphate). GTP (0.5-100 microM) increased the binding of the antagonist [3H]8-cyclopentyl-1,3-dipropylxanthine in all regions, but most markedly in those where GTP had a biphasic effect on agonist binding. Decreasing the levels of endogenous adenosine by increasing the concentration of adenosine deaminase and adding the 5'-nucleotidase inhibitor alpha-beta-methylene adenosine-5'-diphosphate gave an increase in [3H]8-cyclopentyl-1,3-dipropylxanthine binding and diminished the response to GTP. In sections treated with adenosine deaminase and alpha-beta-methylene adenosine-5'-diphosphate, GTP steadily decreased [3H]N6-cyclohexyladenosine binding in all regions. Thus, the GTP-induced increase in both agonist and antagonist binding may be due to a displacement of endogenous adenosine. In the presence of 1 mM EDTA, GTP had a monophasic effect on the binding of [3H]N6-cyclohexyladenosine in all regions. In the presence of 2 mM MgCl2 a biphasic response to GTP was seen in all regions. In EDTA washed sections, the effect of MgCl2 on [3H]N6-cyclohexyladenosine binding was more pronounced in the superior colliculus, where we had observed a biphasic response to GTP. The results suggest that there are regional differences in the effects of GTP on adenosine A1-receptor binding in rat brain, that reflect regional differences in the magnesium-dependent binding of endogenous adenosine, which is bound to the receptor by tight binding, is very difficult to remove, and easily interferes with radioligand binding in in vitro experiments. There may be regional differences in the sensitivity of A1-receptor-G-protein complexes to magnesium, that reflect a heterogeneity of the G-proteins to which the A1-receptors are coupled.

The distribution of adenosine A1 receptors and 5'-nucleotidase in the brain of some commonly used experimental animals.

The distribution of adenosine A1 receptors was studied quantitatively in the brain of the rat, mouse, guinea-pig and cat, using in vitro autoradiography with [3H]N6-cyclohexyladenosine as ligand. Preliminary binding studies in brain sections from the guinea-pig and cat gave results similar to previous data from the rat and showed that the binding site had the pharmacological profile of an A1 receptor. The overall distribution of receptors was comparable in the species studied. The receptors were concentrated in the hippocampus, the cerebral cortex, some thalamic nuclei, the basal ganglia and the cerebellar cortex. The hypothalamus and the brainstem were sparse in receptors. Differences among species in receptor distribution and/or density were seen in some regions, e.g. the cerebral cortex, the striatum, the lateral geniculate nucleus and the cerebellar cortex. The autoradiograms were compared with adjacent sections stained for 5'-nucleotidase. There was in general a poor correlation between the distribution of A1 receptors and 5'-nucleotidase. Furthermore, there were marked differences between species in the distribution of the enzyme. The species differences observed in receptor localization may be of functional relevance.

Adenosine A1 receptors in the human brain: a quantitative autoradiographic study.

The distribution of adenosine A1 receptors in the human brain was studied by autoradiography in post mortem brain tissues from 26 subjects without reported neurological disease. N6-[3H]Cyclohexyl-adenosine was used as the ligand. For comparison, adjacent sections of some regions were examined histochemically for 5'-nucleotidase activity. The receptor sites were heterogeneously distributed throughout the CNS. The highest receptor densities were found in the stratum oriens, pyramidale and radiatum of the hippocampus. High densities were also found in the cerebral cortex and the striatum. In the thalamus there was a heterogeneous distribution of binding sites with a high density in structures such as the medial and anterior nucleus. Intermediate receptor densities were found in the accumbens, the olfactory tubercle and most parts of the amygdala among others. The hypothalamus had low receptor densities. In the brainstem and the spinal cord very low receptor concentrations were found. However, in some structures such as the substantia nigra, the colliculus superior and the substantia gelatinosa of the spinal cord a low level of binding could be measured. The cerebellar cortex showed low densities of receptors. Structures showing high levels of 5'-nucleotidase activity were the hippocampus, the striatum and parts of the cerebral cortex among other regions. In general there was a poor correlation between the localization of A1 receptors and the 5'-nucleotidase activity. Some regions, however, showed a similar distribution of these two markers. In general, the distribution of adenosine A1 receptors found in the human brain is comparable to that found in previous autoradiographic studies in the rat brain. However, some regional differences were observed in, for example, the cerebral cortex, the striatum and the cerebellar cortex. These differences may prove to be functionally relevant.

Alterations in the ryanodine receptor calcium release channel correlate with Alzheimer's disease neurofibrillary and beta-amyloid pathologies.

Investigation of the integrity of the ryanodine receptor in Alzheimer's disease is important because it plays a critical role in the regulation of calcium release from the endoplasmic reticulum in brain, impairment of which is believed to contribute to the pathogenesis of Alzheimer's disease. The present study compared ryanodine receptor levels and their functional modulation in particulate fractions from control and Alzheimer's disease temporal cortex, occipital cortex and putamen. Relationships between ryanodine receptor changes and the progression of Alzheimer's disease pathology were determined by examining autoradiographic [3H]ryanodine binding in entorhinal cortex/anterior hippocampus sections from 22 cases that had been staged for neurofibrillary changes and beta-amyloid deposition. A significant (P < 0.02) 40% decrease in the Bmax for [3H]ryanodine binding and significantly higher IC50 values for both magnesium and Ruthenium Red inhibition of [3H]ryanodine binding were detected in Alzheimer's disease temporal cortex particulate fractions compared to controls. Immunoblot analyses showed Type 2 ryanodine receptor holoprotein levels to be decreased by 20% (P < 0.05) in these Alzheimer's disease cases compared to controls. No significant differences were detected in [3H]ryanodine binding comparing control and Alzheimer's disease occipital cortex or putamen samples. The autoradiography study detected increased [3H]ryanodine binding in the subiculum, CA2 and CA1 regions in cases with early (stage I-II) neurofibrillary pathology when compared to Stage 0 cases. Analysis of variance of data with respect to the different stages of neurofibrillary pathology revealed significant stage-related declines of [3H]ryanodine binding in the subiculum (P < 0.02) with trends towards significant decreases in CA1, CA2 and CA4. Post-hoc testing with Fisher's PLSD showed significant reductions (74-94%) of [3H]ryanodine binding in the subiculum, and CA1-CA4 regions of the late isocortical stage (V-VI) cases compared to the early entorhinal stage I-II cases. [3H]Ryanodine binding also showed significant declines with staging for beta-amyloid deposition in the entorhinal cortex (P < 0.01) and CA4 (P < 0.05) with trends towards a significant decrease in the dentate gyrus. We conclude that alterations in ryanodine receptor binding and function are very early events in the pathogenesis of Alzheimer's disease, and may be fundamental to the progression of both neurofibrillary and beta-amyloid pathologies.

The use of medicines with anticholinergic effects in older people: a population study in an urban area of Sweden.

OBJECTIVE: To investigate the use of medicines with anticholinergic properties among older people in an urban population in Sweden. DESIGN: A cross-sectional survey. SETTING: Ordinary homes, sheltered accommodations, nursing homes, and geriatric departments. PARTICIPANTS: All residents aged 75 and older in a district of Stockholm, Sweden. MEASUREMENTS: Structured interviews with older persons, their relatives and/or health care personnel; prescription forms; medical records. RESULTS: The overall use of medicines with anticholinergic effects was comparatively low. Doses of these medicines were also generally low. Concurrent use of several such medicines was uncommon. The most prevalent therapeutic/pharmacological group was neuroleptics. In contrast, antidepressants were used by few older people. The prevalence of medicines with anticholinergic effects was highest at institutions, where neuroleptics were frequent and use of low-potency neuroleptics was not uncommon. CONCLUSION: Our results indicate that the risk of anticholinergic side effects may be quite low in the present population as a whole. However, there may be grounds for revising the therapy in institutions, where the use of neuroleptics was shown to be high and low-potency neuroleptics, known to have a higher incidence of anticholinergic side effects, were not avoided.

Use of cardiovascular drugs in an older Swedish population.

OBJECTIVE: To describe the use of cardiovascular drugs in an older population with respect to age, sex, housing type, and creatinine clearance. DESIGN: A cross-sectional survey. PARTICIPANTS: All residents of a district of Stockholm (Kungsholmen), Sweden, aged 75 and older, living in institutions or at home. MEASUREMENTS: Cardiovascular drug use, serum creatinine, electrolytes, height, weight, and symptoms. RESULTS: A total of 43 cardiovascular (CV) drugs were used. The most common drugs were digoxin (used by 18.2%), furosemide (16.4%), and glyceryl trinitrate (12.4%). Drugs with an antihypertensive effect accounted for 61% of all CV drugs. CV drug use increased with age for cardiac glycosides and diuretics, but decreased with age for calcium antagonists and beta-blockers. Drug doses tended to be less than the recommended daily dose except for a few drugs, e.g., furosemide. There was a trend toward decreasing dose with increasing age, but this was not significant. Diuretics were the only CV drugs used more often in women. People living in institutional care used the least amount of CV drugs. The dose of drugs taken did not appear to be related to estimated creatinine clearance. Comparisons between drug use and complaint of symptoms showed a strong correlation between the use of cardiac glycosides and anorexia, calcium antagonists and constipation, and nitrates and vertigo. There were weaker correlations with cardiac glycosides and visual disturbances and with potassium sparing diuretics and a high potassium. CONCLUSIONS: CV drugs are used commonly in older people. We suggest that the symptoms correlating with cardiac glycoside use may be signs of unrecognized toxicity, and this may relate to our finding that drug use is often not tailored to renal function as measured by creatinine clearance.

The appropriateness of drug use in an older nondemented and demented population.

OBJECTIVE: To assess the extent of inappropriateness of drug use in an older nondemented and demented population. DESIGN: Descriptive analysis based on data from a sample of older subjects age 81 years and older. Data were collected from the second follow-up conducted in 1994-1996. SETTING: A population-based study of the Kungsholmen project in Stockholm, Sweden. PARTICIPANTS: Drug information was obtained from 681 subjects with a mean age of 86.9 years. The subjects were predominantly women (78%). Thirteen percent resided in institutions and 27.6% were diagnosed with dementia. MEASUREMENTS: Dementia diagnosis based on DSM III-R. Criteria for inappropriateness of drug use: use of drugs with potent anticholinergic properties, drug duplication, potential drug-drug and drug-disease interactions, and inappropriate drug dosage. RESULTS: The mean number of drugs used was 4.6: 4.5 drugs for nondemented and 4.8 for demented subjects. Nondemented subjects more commonly used cardiovascular-system drugs and demented subjects used nervous-system drugs. Demented subjects were more commonly exposed to drug duplication and to drugs with potent anticholinergic properties, both involving the use of psychotropic drugs. Nondemented subjects were more commonly exposed to potential drug-disease interactions, mostly with the use of cardiovascular drugs. The most common drug combination leading to a potential interaction was the use of digoxin with furosemide, occurring more frequently among nondemented subjects. The most common drug-disease interaction was the use of beta-blockers and calcium antagonists in subjects with congestive heart failure. The doses of drugs taken by both nondemented and demented subjects were mostly lower than the defined daily dose. CONCLUSION: There was substantial exposure to presumptive inappropriateness of drug use in this very old nondemented and demented population. The exposure of demented subjects to psychotropic drugs and nondemented subjects to cardiovascular drugs reflect the high frequency of prescribing these drugs in this population.

Mild cognitive impairment in the population and physical health: data on 1,435 individuals aged 75 to 95.

BACKGROUND: The physical health correlates of mild cognitive impairment (MCI) in the older individual are poorly known. The aim of this study was to investigate the relationship between physical health and MCI with population data. METHODS: Subjects were 1,435 nondemented 75- to 95-year-old subjects. MCI was defined as scoring one standard deviation below age- and education-specific means on the Mini-Mental State Examination. MCI was consistently associated with indicators of poorer health in logistic regression models with adjustment for potential confounders. RESULTS: The adjusted odds ratios for those with two, three, four, or more somatic symptoms compared with those with one or no symptoms were 1.3 (95% confidence intervals 1.0 to 1.9) and 2.1 (1.2 to 4.5; p for trend =.004); for those with poor self-rated health the odds ratio was 1.9 (1.4 to 2.6); for those with one, two, or more chronic diseases compared with those with no chronic diseases, the odds ratios were 1.3 (0.9 to 1.9) and 3.0 (1.2 to 7.6; p for trend =.02); and for those dying during the 3-year follow-up period the odds ratio was 1.5 (1.1 to 2.2). CONCLUSIONS: MCI is associated with poor physical health, leading to the hypothesis of a causal relationship between physical diseases and MCI in older populations.

Inhibition of [3H]forskolin binding by Gpp[NH]p may reflect adenylyl cyclase coupling to Gi.

The effect of the GTP-analogue guanylyl 5'-imidodiphosphate (Gpp[NH]p) on [3H]forskolin binding was studied in rat brain using autoradiography. In the striatum, 100 microM Gpp[NH]p produced a 40% increase in binding, whereas a decrease of about 30% was observed with low Gpp[NH]p concentrations (0.1-1 microM). In the molecular layer of the cerebellum all concentrations of Gpp[NH]p decreased [3H]forskolin binding. The decrease in binding disappeared in both striatum and the molecular layer of cerebellum in sections pretreated with 100 microM N-ethylmaleimide (NEM) for 10 min. NEM pretreatment did not significantly affect the stimulation of [3H]forskolin binding by micromolar concentrations of Gpp[NH]p in the striatum, but reversed the decrease observed in the molecular layer of the cerebellum, to an increase. Based on these data we suggest that the effects of the GTP-analogue Gpp[NH]p on [3H]forskolin binding may involve both Gs and Gi, where a stimulation produces an increase and decrease in binding respectively. The regional effects of Gpp[NH]p may reflect differences in the responsiveness of adenylyl cyclase to Gs and Gi-mediated effects.

Inhibition of [3H]forskolin binding by Gpp[NH]p may reflect adenylate cyclase coupling to Gi.

The effect of the GTP analogue guanylyl-5'-imidodiphosphate (Gpp[NH]p) on [3H]forskolin binding was studied in rat brain using autoradiography. In the striatum the presence of 100 microM Gpp[NH]p produced a 40% increase in binding, whereas a decrease of about 30% was observed with low Gpp[NH]p concentrations (0.1 microM). In the molecular layer of the cerebellum all concentrations of Gpp[NH]p decreased [3H]forskolin binding. The decrease in binding disappeared in both striatum and the molecular layer of cerebellum in sections pretreated with 100 microM N-ethylmaleimide (NEM) for 10 min. NEM pretreatment did not significantly affect the stimulation of [3H]forskolin binding by micromolar concentrations of Gpp[NH]p in the striatum, but reversed the decrease observed in the molecular layer of the cerebellum, to an increase. Based on these data we suggest that the effects of Gpp[NH]p on [3H]forskolin binding may involve both Gs and Gi, where stimulation produces an increase and decrease in binding, respectively. The regional effects of Gpp[NH]p may reflect differences in the responsiveness of adenylate cyclase to Gs- and Gi-mediated effects.

Effects of oxytocin on in vivo release of insulin and glucagon studied by microdialysis in the rat pancreas and autoradiographic evidence for [3H]oxytocin binding sites within the islets of Langerhans.

In the present investigation it was studied whether oxytocin administered directly in the pancreas of the rat stimulates the release of insulin and glucagon. In order to study such effects in vivo, a new experimental model applying the microdialysis technique was developed. To test the validity of the method, glucose or arginine were infused i.v. and it was shown that perfusate concentrations of insulin and glucagon increased significantly to 344 and 292% of basal overflow, respectively. Administration of oxytocin via the dialysis probe into the splenic portion of the pancreas resulted in significant elevations of insulin and glucagon concentrations to 210 (P less than 0.05) and 528% (P less than 0.01), respectively. The present study also includes a combined autoradiographic and immunohistochemical investigation of binding sites for oxytocin in the rat pancreas. A high density of [3H]oxytocin binding was present in the periphery of the islets of Langerhans, corresponding to the localization of the glucagon-producing alpha-cells. Both oxytocin and arginine(A)-vasopressin displaced [3H]oxytocin. The IC50 values were 10 and 180 nM, respectively. In conclusion, the oxytocin-induced release of insulin and glucagon as previously demonstrated in a number of species, may be due to a stimulation exerted by the peptide directly within the pancreas.