Serotonin syndrome associated with polypharmacy in the elderly

The increasing use of serotonergic agents, alone and in combination, across multiple disciplines, makes it likely that the prevalence of serotonin syndrome will rise. Caution should be used, especially in the elderly, to avoid unnecessary and potentially harmful polypharmacy. We describe a case of serotonin syndrome in a 79-year-old man taking mirtazapine, venlafaxine and quetiapine. As this case illustrates, serotonin syndrome can be caused by combinations of direct serotonin agonists (e.g., serotonergic antidepressants) and indirect serotonin agonists (e.g., atypical antipsychotics).     

Medical status of elderly patients consulting two oral and maxillofacial surgery departments in Germany

An increasing number of elderly patients requires dental care. The data concerning the medical risk profile of seniors consulting dentists are scarce. In this context, the comorbidity-polypharmacy-score (CPS) could be an effective clinical tool to quickly assess the medical status of elderly patients. The medical data from 648 patients (60 years and older) of two cohorts (Fulda group [Fg] and Marburg group [Mg]) from two maxillofacial surgical units were recorded using a standardised questionnaire and compared concerning the number of the regular medications and the CPS. No medication was needed in 57 patients and 311 took 1 to 4 medications per day. Polypharmacy (5 or more medications per day) could be observed in 280 patients. The average medication was 4.28 in the Fg and 4.57 in the Mg groups (p = 0.249). Antihypertensives and antithrombotics were the most common medications. The CPS was subdivided into three groups (minor, moderate, severe). In total, 332 patients belonged to the minor group and 80 to the severe group. The average CPS was 7.49 in the Fg and 7.99 in the Mg groups (not significant). CPS was strongly correlated with age (p < 0.001) but not with sex. The prevalence of elderly patients with polypharmacy presenting for dental care is increasing. Scores like CPS may be a useful adjunct for quantifying the burden of disease in the context of dental treatment.     

Deprescripción en personas mayores: es el momento de pasar a la acción

El uso de fármacos conlleva innegables beneficios en las personas mayores, pero no está exento de efectos indeseables. La deprescripción es el proceso de revisión sistemática de la medicación con el objetivo de lograr la mejor relación riesgo-beneficio en base a la mejor evidencia disponible. Este proceso es especialmente importante en mayores polimedicados, sobretratados, frágiles, con enfermedades terminales y en el final de la vida.La deprescripción debe hacerse de forma escalonada, estableciendo un seguimiento estrecho por si aparecen problemas tras la retirada. En la toma de decisiones es muy importante contar con la opinión del paciente y de los cuidadores, valorando los objetivos del tratamiento según la situación clínica, funcional y social del enfermo.Existen múltiples herramientas para facilitar a los clínicos la tarea de seleccionar qué fármacos deprescribir (criterios Beers, STOPP-START…). Los grupos farmacológicos más susceptibles de intervención son: antihipertensivos, antidiabéticos, estatinas, benzodiacepinas, antidepresivos, anticolinérgicos, anticolinesterásicos y neurolépticos.Palabras clave: Polifarmacia, Envejecimiento, Comorbilidad, Prescripción inadecuada, Efectos adversos, Deprescripción     

影响拟行外科手术高龄患者基础肾功能的危险因素分析

目的 研究拟行外科手术高龄(≥75岁)患者基础肾功能的危险因素,为高危患者及时修正可改变因素,并为围术期精准用药提供依据.方法 回顾性分析2016年1月～2019年12月在首都医科大学宣武医院骨科、神经外科、普通外科、泌尿外科住院的高龄患者的临床资料.根据改善全球肾脏病预后组织(KDIGO)指南,将患者分为肾功能损伤组...     

Transcranial magnetic stimulation (TMS) for geriatric depression

BackgroundThe prevalence of treatment-resistant geriatric depression (GD) highlights the need for treatments that preserve cognitive functions and recognize polypharmacy in elderly, yet effectively reduce symptom burden. Transcranial magnetic stimulation (TMS) is a proven intervention for treatment-resistant depression in younger adults but the efficacy of TMS to treat depressed older adults is still unclear. This review provides an updated view on the efficacy of TMS treatment for GD, discusses methodological differences between trials in TMS application, and explores avenues for optimization of TMS treatment in the context of the ageing brain.MethodsA systematic review was conducted to identify published literature on the antidepressant efficacy of TMS for GD. Databases PubMed, Embase, and PsycINFO were searched for English language articles in peer-reviewed journals in March 2021.ResultsSeven randomized controlled trials (RCTs) (total n = 260, active n = 148, control n = 112) and seven uncontrolled trials (total n = 160) were included. Overall, we found substantial variability in the clinical response, ranging from 6.7% to 54.3%.ConclusionsThe reviewed literature highlights large heterogeneity among studies both in terms of the employed TMS dosage and the observed clinical efficacy. This highlights the need for optimizing TMS dosage by recognizing the unique clinical features of GD. We showcase a set of novel approaches for the optimization of the TMS protocol for depression and discuss the possibility for a standardized TMS protocol tailored for the treatment of GD.     

Polypharmacy and Kidney Function in Community-Dwelling Adults Age 60 Years and Older: A Prospective Observational Study

ObjectivesInformation on the impact of polypharmacy on kidney function in older adults is limited. We prospectively investigated the association between intake of total number of drugs or nonsteroidal anti-inflammatory drugs (NSAIDs) and kidney function.DesignOur study is a prospective observational analysis of the 2-year Zurich Multiple Endpoint Vitamin D Trial in Knee Osteoarthritis Patients.Setting and participantsOf the 273 participants of the original trial, 270 participants (mean age 70.3 ± 6.4 years, 53% women) were included in this observational analysis.MethodsThe associations between (1) total number of drugs (or NSAIDs) at baseline or (2) cumulative number of drugs (or NASAIDs) repeatedly measured over 24 months and kidney function repeatedly measured over 24 months as estimated glomerular filtration rate (eGFR) were investigated using multivariable-adjusted repeated-measures analysis.ResultsPer drug at baseline, kidney function decreased by 0.64 mL/min/1.73 m² eGFR (Beta = −0.64; 95% CI −1.19 to −0.08; P = .024) over 24 months. With every additional drug taken cumulatively over 24 months, kidney function decreased by 0.39 mL/min/1.73 m² eGFR (Beta = −0.39; 95% CI −0.63 to −0.15; P = .002). In a high-risk subgroup, per NSAID taken cumulatively over 24 months, kidney function declined by 1.21 mL/min/1.73 m² eGFR (Beta = −1.21; 95% CI −2.35 to −0.07; P = .021).Conclusions and implicationsFor every additional drug prescribed among older adults, our study supports an independent and immediate harmful impact on kidney function. This negative impact seems to be about 3 times greater for NSAIDs compared with an additional average drug.