RESUMEN
OBJECTIVE: To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper, stop, or switch antihyperglycemic agents in older adults. METHODS: We focused on the highest level of evidence available and sought input from primary care professionals in guideline development, review, and endorsement processes. Seven clinicians (2 family physicians, 3 pharmacists, 1 nurse practitioner, and 1 endocrinologist) and a methodologist comprised the overall team; members disclosed conflicts of interest. We used a rigorous process, including the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, for guideline development. We conducted a systematic review to assess evidence for the benefits and harms of deprescribing antihyperglycemic agents. We performed a review of reviews of the harms of continued antihyperglycemic medication use, and narrative syntheses of patient preferences and resource implications. We used these syntheses and GRADE quality-of-evidence ratings to generate recommendations. The team refined guideline content and recommendation wording through consensus and synthesized clinical considerations to address common front-line clinician questions. The draft guideline was distributed to clinicians and stakeholders for review and revisions were made at each stage. A decision-support algorithm was developed to accompany the guideline. RECOMMENDATIONS: We recommend deprescribing antihyperglycemic medications known to contribute to hypoglycemia in older adults at risk or in situations where antihyperglycemic medications might be causing other adverse effects, and individualizing targets and deprescribing accordingly for those who are frail, have dementia, or have a limited life expectancy. CONCLUSION: This guideline provides practical recommendations for making decisions about deprescribing antihyperglycemic agents. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients.
Asunto(s)
Humanos , Anciano , Anciano de 80 o más Años , Diabetes Mellitus/tratamiento farmacológico , Receptores de Sulfonilureas/efectos de los fármacos , Deprescripciones , Hiperglucemia/tratamiento farmacológico , Hipoglucemiantes/administración & dosificación , Insulina/administración & dosificación , Toma de Decisiones Clínicas , Hipoglucemiantes/efectos adversos , Insulina/efectos adversosRESUMEN
OBJECTIVE: To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper or stop proton pump inhibitors (PPIs); to focus on the highest level of evidence available and seek input from primary care professionals in the guideline development, review, and endorsement processes. METHODS: Five health professionals (1 family physician, 3 pharmacists, and 1 gastroenterologist) and 5 nonvoting members comprised the overall team; members disclosed conflicts of interest. The guideline process included the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, with a detailed evidence review in in-person, telephone, and online meetings. Uniquely, the guideline development process included a systematic review of PPI deprescribing trials and examination of reviews of the harm of continued PPI use. Narrative syntheses of patient preferences and resource-implication literature informed recommendations. The team refined guideline content and recommendation wording through consensus and synthesized clinical considerations to address common front-line clinician questions. The draft guideline was distributed to clinicians and then to health care professional associations for review and revisions made at each stage. A decision-support algorithm was developed in conjunction with the guideline. RECOMMENDATIONS: This guideline recommends deprescribing PPIs (reducing dose, stopping, or using "on-demand" dosing) in adults who have completed a minimum of 4 weeks of PPI treatment for heartburn or mild to moderate gastroesophageal reflux disease or esophagitis, and whose symptoms are resolved. The recommendations do not apply to those who have or have had Barrett esophagus, severe esophagitis grade C or D, or documented history of bleeding gastrointestinal ulcers. CONCLUSION: This guideline provides practical recommendations for making decisions about when and how to reduce the dose of or stop PPIs. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients.
Asunto(s)
Humanos , Adulto , Inhibidores de la Bomba de Protones/administración & dosificación , Deprescripciones , Enfermedades Gastrointestinales/tratamiento farmacológico , Reflujo Gastroesofágico/tratamiento farmacológico , Esofagitis/tratamiento farmacológico , Inhibidores de la Bomba de Protones/efectos adversos , Toma de Decisiones Clínicas , Pirosis/tratamiento farmacológicoRESUMEN
Behavioral and psychological symptoms of dementia can occur in 60-80% of patients with Alzheimer's disease or other dementing illnesses, and are important in that they are a source of significant caregiver stress and often precipitate nursing home placement. These symptoms, namely, aggression, delusions, hallucinations, apathy, anxiety, and depression, are clinically managed with a variety of psychotropic drugs such as antipsychotics, antidepressants, antiepileptic drugs, and benzodiazepines. Various advances in the neuropathophysiology and pharmacotherapy must be considered in the optimal design of regimens for patients with these symptoms.
Asunto(s)
Conducta/fisiología , Demencia/tratamiento farmacológico , Demencia/psicología , Psicotrópicos/uso terapéutico , Enfermedad de Alzheimer/tratamiento farmacológico , Enfermedad de Alzheimer/epidemiología , Enfermedad de Alzheimer/psicología , Animales , Demencia/epidemiología , Humanos , Escalas de Valoración PsiquiátricaRESUMEN
OBJECTIVE: To report a case of the successful use of donepezil for treatment of cognitive and noncognitive symptoms in a patient with dementia with Lewy bodies. CASE SUMARY: An 86-year-old white woman with dementia was experiencing early-onset significant fluctuation of her cognitive status, functional impairment, visual hallucinations, aggression, and parkinsonism. She was intially diagnosed with Alzheimer disease and Parkinsons disease and prescribed donepezil 5 mg/d and benztropine 1 mg twice daily. On reexamination of the case by a neurologist, the diagnoses were revised to dementia with Lewy bodies. The benztropine was discontinued, and donepezil was increased to 10 mg/d. The patient's cognitive and functional status significantly improved, as did her visual hallucinations. DISCUSSION: This case supports previous reports of the marked responsiveness of patients with dementia with Lewy bodies to acetylcholinesterase inhibitors. This may be explained by the marked cholinergic deficit observed in patients with dementia with Lewy bodies and the evidence linking cognitive as well as noncognitive symptoms to this deficit. CONCLUSIONS: The present case suggests that patients with dementia with Lewy bodies respond well to acetylcholinesterase inhibitors. Controlled trials are necessary to further define the role of these drugs for this disease.
Asunto(s)
Inhibidores de la Colinesterasa/uso terapéutico , Indanos/uso terapéutico , Enfermedad por Cuerpos de Lewy/tratamiento farmacológico , Nootrópicos/uso terapéutico , Piperidinas/uso terapéutico , Anciano , Anciano de 80 o más Años , Donepezilo , Femenino , Humanos , Enfermedad por Cuerpos de Lewy/psicologíaAsunto(s)
Antiinflamatorios no Esteroideos/administración & dosificación , Anticoagulantes/uso terapéutico , Sulfonamidas/administración & dosificación , Warfarina/uso terapéutico , Anciano , Anciano de 80 o más Años , Celecoxib , Interacciones Farmacológicas , Femenino , Evaluación Geriátrica , Humanos , Relación Normalizada Internacional , PirazolesAsunto(s)
Inhibidores de la Colinesterasa/metabolismo , Indanos/metabolismo , Piperidinas/metabolismo , Antidepresivos de Segunda Generación/farmacología , Antifúngicos/farmacología , Inhibidores de la Colinesterasa/farmacocinética , Cimetidina/farmacología , Inhibidores Enzimáticos del Citocromo P-450 , Donepezilo , Interacciones Farmacológicas , Inhibidores Enzimáticos/farmacología , Humanos , Indanos/farmacocinética , Cetoconazol/farmacología , Paroxetina/farmacología , Piperidinas/farmacocinéticaRESUMEN
Falls are a significant cause of fatal and nonfatal injuries in older persons. Risk factors include previous falls, several disease states, and certain drugs such as tricyclic antidepressants and antihypertensives. We conducted a MEDLINE search from January 1966-March 1999 to identify studies and review articles on the association of neuroleptics, benzodiazepines, and antidepressants with fall risk in older people. The focus was on the risk associated with serotonin reuptake inhibitors, biologic plausibility, and limitations of these studies. It was thought that the agents did not increase the risk of falls, although recent evidence suggests that this is not the case.
Asunto(s)
Accidentes por Caídas , Psicotrópicos/efectos adversos , Inhibidores Selectivos de la Recaptación de Serotonina/efectos adversos , Anciano , Estudios de Cohortes , Humanos , Factores de RiesgoRESUMEN
Because benzodiazepines can cause significant morbidity and data of their use in elderly people in Canada are scarce, the patterns of benzodiazepine use by Nova Scotia's seniors were studied with the use of administrative, population-based data. The prevalence of benzodiazepine use in the fiscal years 1993/94 to 1995/96 was explored, the types of benzodiazepines used and the extent of use for periods exceeding 30 days were examined, and an attempt was made to examine the average daily doses used. Benzodiazepine use decreased from 28.74% in 1993/94 to 24.69% in 1995/96 (P<0.001). Long elimination half-life benzodiazepines accounted for 23% of benzodiazepines in 1995/96. The proportion of benzodiazepines filled for periods exceeding 30 days increased from 65% in 1993/94 to 68% in 1995/96 (P<0.001). Variability in the estimated daily doses of the benzodiazepines was such that comparison with recommended dose maxima could not be made with confidence, even though the averages of these estimated daily doses appeared to exceed recommended maxima, except for users of alprazolam, lorazepam, oxazepam or bromazepam. Although benzodiazepine use decreased, the observed patterns of use may place seniors at unnecessary risk for adverse health outcomes and increased health resource utilization.
Asunto(s)
Benzodiazepinas/uso terapéutico , Quimioterapia/tendencias , Anciano , Benzodiazepinas/efectos adversos , Estudios Transversales , Recolección de Datos , Utilización de Medicamentos , Humanos , Nueva EscociaRESUMEN
Alzheimer's disease accounts for 50-60% of dementia cases in older people. Dementia with Lewy bodies is now recognized as the second most common type of dementia. It is different from Alzheimer's disease and has important pharmacotherapeutic implications. Key features include early-onset, persistent, well-formed, visual hallucinations and motor features of parkinsonism. Pharmacologic management of neurobehavioral symptoms is complicated by an exaggerated response to neuroleptics, which causes excessive morbidity and mortality. Patients with dementia with Lewy bodies may be particularly responsive to cholinesterase inhibitors. When neurobehavioral symptoms are severe enough to require pharmacologic intervention, it is recommended that agents such as trazodone or cholinesterase inhibitors be considered first-line therapy. If these fail, neuroleptics may be prescribed with caution.
Asunto(s)
Demencia/patología , Cuerpos de Lewy/patología , Demencia/terapia , HumanosRESUMEN
OBJECTIVE: To determine current patterns of acetylsalicylic acid (ASA) use in Nova Scotia for individuals with self-reported myocardial infarction, stroke or ischemic heart disease. DESIGN: Descriptive, cross-sectional, population-based study using data from the 1995 Nova Scotia Health Survey (NSHS). The NSHS was based on a probability sample and was representative of the Nova Scotia adult population by age, sex and region. Survey data were obtained by standardized home interviews conducted by trained public health nurses. SETTING: The province of Nova Scotia in 1995. PARTICIPANTS: Survey respondents who reported having a myocardial infarction, stroke or ischemic heart disease were assessed. RESULTS: Among those who reported a history of myocardial infarction, stroke or ischemic heart disease, 55% (95% CI 47% to 63%), 49% (95% CI 38% to 61%) and 54% (95% CI 39% to 68%), respectively, reported using ASA at the time of the survey. Overall, only 53% of those with cardiovascular disease were using ASA. Exclusion of persons with potential contraindications to ASA did not significantly increase these proportions. CONCLUSIONS: ASA appears to be underused in those at high risk for future vascular events. Further research is required to investigate determinants of ASA use and to increase appropriate use of ASA.
Asunto(s)
Antiinflamatorios no Esteroideos/uso terapéutico , Aspirina/uso terapéutico , Trastornos Cerebrovasculares/prevención & control , Infarto del Miocardio/prevención & control , Vigilancia de la Población , Adolescente , Adulto , Anciano , Trastornos Cerebrovasculares/epidemiología , Estudios Transversales , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Isquemia Miocárdica/epidemiología , Isquemia Miocárdica/prevención & control , Medicamentos sin Prescripción , Nueva Escocia/epidemiología , Cooperación del Paciente/estadística & datos numéricos , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
This descriptive, retrospective, population-based study assessed patterns of antidepressant medication use in elderly patients in Nova Scotia during fiscal years 1993 through 1996. Individuals > or =65 years of age who were registered with Nova Scotia's Seniors Pharmacare program and filled a prescription for an antidepressant medication during the specified period were included in the study. We determined the number of individuals who filled > or =1 prescription for an antidepressant, the number whose prescription for an antidepressant could be matched with a diagnosis of depression in the physician's billing database, the number who used antidepressants that were judged inappropriate based on published criteria for medication prescribing in the elderly, the number who used a therapeutic antidepressant dose based on published dosing guidelines for the elderly, and the number who used antidepressants for > or =6 months. A total of 12,048, 12,317, and 13,419 individuals filled prescriptions for antidepressants during the 1993 to 1994, 1994 to 1995, and 1995 to 1996 fiscal years, respectively. In each fiscal year, approximately 70% had received a diagnosis of depression based on the International Classification of Diseases, Ninth Revision, Clinical Modification, making it likely that 70% of antidepressant users were receiving these drugs for a primary diagnosis of depression. The number of antidepressant prescriptions that were classified as inappropriate for use in the elderly was 67% in 1993 to 1994, 61% in 1994 to 1995, and 55% in 1995 to 1996. These decreases over time were statistically significant (P < 0.001). Among those using serotonin reuptake inhibitors, secondary tricyclic antidepressants, or tertiary tricyclic antidepressants, 79%, 45%, and 31%, respectively, appeared to be using therapeutic doses. Of 23,553 antidepressant treatment courses, 11,028 (47%) were for < or =180 days. During the study, a significant number of elderly individuals were prescribed antidepressant medications that are judged by expert consensus to be inappropriate for use in this population because of an unfavorable toxicity profile, although the number declined significantly from year to year (P < 0.001 for year-to-year comparisons). Many individuals also appeared to be using antidepressant doses that are probably subtherapeutic, but this finding seemed heavily dependent on the class of antidepressant used. Nearly half of the individuals studied appeared to be treated for inadequately short periods.