An empirical evaluation of the Global Deterioration Scale for staging Alzheimer's disease.

OBJECTIVE: Although the Global Deterioration Scale has been widely used since its publication in 1982, its stages are based on implicit assumptions about the linearity, temporality, and interdependence of cognitive, functional, and behavioral impairment in Alzheimer's disease. The authors evaluated the validity of these assumptions and tested the hypothesis that psychopathology and functional impairment would occur in earlier stages than the Global Deterioration Scale predicts. METHOD: The analyses were based on data on 324 patients with Alzheimer's disease who were selected from a registry of such patients. Data analyses included 1) descriptive statistics on the frequency of psychiatric symptoms and difficulties with activities of daily living and 2) logistic regression, with symptoms and functional impairment as independent variables, to test for significant changes in patients' status between stages of the Global Deterioration Scale. RESULTS: More than 50% of the patients at stage 2 displayed psychopathology, and 32% had two or more symptoms. The significant increase in psychiatric symptoms occurred between stages 3 and 4, not between stages 5 and 6 as predicted by the Global Deterioration Scale. Impairment in functional status was observed at all stages, and significant increases occurred between stages 3 and 4 as well as between stages 5 and 6. CONCLUSIONS: Psychiatric symptoms and functional impairment occur earlier than predicted by the Global Deterioration Scale, and the rate of change is also different from that specified in the scale. Separate scales to describe cognitive, clinical, and functional status may be the best way to describe the illness until better multidimensional instruments are developed.

Effect of the Omnibus Reconciliation Act 1987 on antipsychotic prescribing in nursing home residents.

OBJECTIVE: To determine the impact of OBRA 87 on antipsychotic prescribing in a 485-bed nursing home. DESIGN: Twelve-month retrospective cohort review of medical charts, medication administration records, and computerized pharmacy records. MEASUREMENTS: The percent of residents by diagnostic group and antipsychotic use. MAIN RESULTS: An attempt was made to stop or lower the dose of antipsychotic in 75% of the 107 residents studied. Antipsychotics were stopped in 45% of residents with a dementia-only diagnosis and 25% of residents with a psychiatric diagnosis (P < 0.05). Residents with documented symptoms appropriate for the use of antipsychotic, per OBRA 87, were significantly less likely to have their antipsychotic stopped. Twenty percent of residents whose antipsychotic was either stopped or its dose lowered had the agent restarted or its dose increased. CONCLUSION: OBRA 87 had a significant impact on antipsychotic use in this facility.

Drug use patterns of persons with Alzheimer's disease and related disorders living in the community.

OBJECTIVE: To describe drug use patterns by persons with Alzheimer's disease, multi-infarct dementia, and mixed Alzheimer's disease and multi-infarct dementia. DESIGN: Multicenter, patient registry. SETTING: Community-living persons evaluated in primary care, geriatric, and Alzheimer ambulatory settings. PARTICIPANTS: Of the 930 persons in three diagnostic categories, there were 671 with probable or possible Alzheimer's disease by NINCDS/ADRDA criteria or Alzheimer's disease by DSM-III-R criteria, 162 multi-infarct cases by DSM-III-R criteria, and 97 mixed cases by DSM-III-R criteria. In each diagnostic category, 65% were women, and the majority were 70 years or older. MEASUREMENTS: The average number of all prescription and non-prescription drugs and selected therapeutic categories by age, sex, diagnosis, and mini-mental status score at the time of diagnosis or evaluation. RESULTS: Alzheimer patients average 2.3 drugs compared with multi-infarct (4.3; P < 0.0001) and mixed (3.7; P = 0.002) patients, and their pattern of drug use was different when stratified by therapeutic categories and drug classes. Drug use increased with age, and women used significantly more drugs than men in all three diagnostic categories. Women with Alzheimer's disease used significantly more cardiovascular drugs than men with Alzheimer's disease (P < 0.05). The lower the mini-mental status score in patients with any dementia, the greater the mean number of central nervous system agents used. The higher the mini-mental status score in a patient with multi-infarct or mixed dementia, the greater the use of cardiovascular drugs. CONCLUSION: Drug use by Alzheimer patients was lower than in multi-infarct and mixed patients, primarily due to a lower prevalence of cardiovascular drugs.

Medication use characteristics in the elderly: the Iowa 65+ Rural Health Study.

Medication use was studied in a rural, elderly population. Household interviews were conducted of 3,467 individuals aged 65 years or older. A total of 9,955 prescription or nonprescription drugs were reported by the respondents. The overall mean number of drugs per respondent was 2.87, while 12% of all respondents were not taking any drugs. Mean prescription and overall drug use increased significantly with increasing age (P less than .001), while mean nonprescription drug use was relatively constant across age groups. Significantly more women were prescription and nonprescription drug users. Directions for scheduled daily dosing accounted for 75% of all directions. The majority of prescription and nonprescription drugs had been taken on the previous day. General practitioners accounted for more prescription drugs (39.7%) than any other medical specialty. The most frequently stated purpose was cardiovascular for prescription drugs and musculoskeletal for nonprescription drugs. The three most frequent prescription drug therapeutic categories were cardiovascular (54.7%), central nervous system (CNS) agents (11.4%), and analgesics (9.4%). For nonprescription drugs, the three most frequent therapeutic categories were analgesics (39.6%), vitamins and minerals (32.9%), and laxatives (14.1%). Implications of these findings are discussed.

Role of risk assessment and bone density monitoring in osteoporosis.

Osteoporosis and its complications are prevalent medical problems. Of the risk factors for fractures, low bone mass is the best predictor. Measuring bone density in a person with risk factors for osteoporosis can provide important information for both patient and physician when choosing clinical interventions. For patients with the disease it is a way to assess response to drug therapy. Advances in technology have made measuring bone density safer, faster, and more practical than ever. Guidelines addressing when, where, and how the test should be done are useful when deciding how to apply this technology to patient care.

Psychotropic drug use in relation to psychiatric symptoms in community-living persons with Alzheimer's disease.

We attempted to determine the relationship between psychiatric symptoms and psychotropic drug use in persons with Alzheimer's disease based on a multicenter patient registry of 671 community-living persons diagnosed with the disease by published criteria. Logistic regression was performed to determine which symptoms were associated psychotropic use after controlling for age, sex, and Mini-Mental Status Examination (MMSE) score. At least one psychotropic drug was reported by 31% of patients, and 66% had at least one psychiatric symptom. Antipsychotics were associated with a lower MMSE score (odds ratio = 0.92, 95% confidence interval 0.88-0.97), emotional lability (OR = 4.52, 95% CI 1.69-11.94), and hallucinations (OR = 6.54, 95% CI 2.99-14.26). Antidepressants were associated with depressive symptoms (OR = 5.8, 95% CI 2.61-13.46), and benzodiazepines with a lower MMSE score (OR = 0.93, 95% CI 0.90-0.97). Community-living persons with Alzheimer's disease are frequently prescribed psychotropic drugs; however, more than 50% of patients with a psychiatric symptom did not report taking one of these agents. This suggests that alternative therapies and no treatment are also prevalent.

Depression in the medically ill elderly: a focus on methylphenidate.

OBJECTIVE: To describe depression in the medically ill elderly and discuss methylphenidate as a treatment option. DATA SOURCES: A MEDLINE search from 1986 to 1995 was done to identify the literature published on depression in the medically ill as well as the literature on the use of methylphenidate for depression in the medically ill elderly. The references of articles found were evaluated for other relevant articles. STUDY SELECTION: Retrospective and prospective studies that evaluated the use of methylphenidate in depressed, medically ill elderly were reviewed. DATA EXTRACTION: Information on depression in the medically ill elderly was abstracted from original and review articles on the subject. The information pertaining to methylphenidate came from clinical studies. CONCLUSIONS: Depression in the medically ill elderly occurs frequently and is underdetected in part because of the difficulty in diagnosing depression in this population. Methylphenidate has been found to be a safe and effective treatment of depression in the medically ill elderly. A potential advantage of methylphenidate over other antidepressants is its relatively quick onset of action, usually within 2-5 days. Older patients whose depressive symptoms are interfering with their functional capabilities or participation in prescribed therapies to improve or restore function after a medical illness should be considered for a trial of methylphenidate.

Assessment of medication management skills in older outpatients.

OBJECTIVE: To identify risk factors for poor medication management skills in community-dwelling older adults by using a performance-based medication management assessment instrument. DESIGN: A cross-sectional investigation. SETTING: A university outpatient geriatric assessment clinic. PARTICIPANTS: Fifty-nine community-dwelling older adults aged 62-102 years. MEASUREMENTS: Patients were assessed on their ability to perform medication management tasks, including reading prescription labels, interpreting medication instructions, opening safety-capped vials, removing tablets from vials, and differentiating tablet colors. The Mini-Mental State Examination (MMSE) was administered and the Katz index of activities of daily living was obtained during the same clinic visit. RESULTS: Cognitive impairment (MMSE < 24) and physical dependency (Katz > or = 1) were both found to be risk factors for the inability to perform individual tasks and independent risk factors for poor overall outcome on the medication management assessment, odds ratios (95% confidence interval) 9.39 (7.82 to 10.96) and 7.24 (5.60 to 8.88), respectively. Age, gender, education, or number of prescription medications were not associated with the ability to perform individual tasks or to overall outcome on the medication management assessment. CONCLUSIONS: Cognitive deficits and physical dependency appear to be strong predictors for the inability to perform tasks associated with medication management. Assessment of medication management skills in older adults living in the community may help identify specific problems, aid in planning patient care, and promote independence.

Recent advances in geriatrics: drug-related problems in the elderly.

OBJECTIVE: To review recent articles examining drug-related problems in the elderly and comment on their potential impact on geriatric pharmacy practice. DATA SOURCES: Six articles published in 1997 and 1998. DATA SYNTHESIS: One study estimated that the cost of drug-related morbidity and mortality with the services of consultant pharmacists was $4 billion, compared with $7.6 billion without the services of consultant pharmacists. A study of ambulatory elderly patients with polypharmacy documented that 35% reported experiencing at least one adverse drug event within the previous year. Another study of ambulatory elderly found that in those with discontinued medications, adverse drug withdrawal events were uncommon. Two studies, one from Canada and one from the US, describe the development, by consensus, of explicit criteria for defining and identifying inappropriate drug use in the elderly (i.e., drugs to avoid, drugs with dose limits, drug-drug and drug-disease interactions). Finally, a modified Delphi survey of an expert panel reached consensus on 18 potential risk factors for drug-related factors in long-term care facility residents. CONCLUSIONS: Drug-related problems are considerable for elderly patients. Data from published studies should provide some guidance for today's practitioners as well as direction regarding future research.

Perceived purpose of prescription drugs: the Iowa 65+ Rural Health Study.

In order to assess elderly patients' knowledge of their medications, the Iowa 65+ Rural Health Study asked a rural, elderly population the purpose of their prescription drugs. Ten percent of all drug purposes reported were considered inappropriate by our criteria. There was some variability between therapeutic categories and their frequency of purpose misperception. For 40 percent of drugs whose purpose was inappropriate, the respondent reported another drug for which that purpose would have been appropriate. Respondents were as likely to state a medication's appropriate purpose whether it had been dispensed by a pharmacy or a physician. The highest percentage of drugs whose purpose was appropriately perceived was dispensed by mail-order pharmacies.

Use of medications by persons 65 and over: data from the established populations for epidemiologic studies of the elderly.

Data were analyzed from household interviews of four population-based cohorts comprising the Established Populations for Epidemiologic Studies of the Elderly to estimate the prevalence of prescription and nonprescription medication use among community-living elderly and to examine sociodemographic and health factors related to medication use. Prescription drugs were used by 60-68% of men and 68-78% of women. Nonprescription drugs were used by 52-68% of men and 64-76% of women. Use of prescription medications generally increased with age although use of nonprescription drugs was not associated with age. Men and women who smoked or used alcohol in the preceding year frequently took medications. Those who reported more depressive symptoms, impairments in physical functioning, hospitalizations, and had poorer self-perceived health status were most likely to take medications. However, 10-29% of respondents with fair or poor self-perceived health took no prescription medications, and 3-13% took neither prescription nor nonprescription medications. While further research appears warranted into potential overmedication of elders, particularly those with many depressive symptoms, these data suggest that studies of potential underuse among elders with poor health are equally important.