ECT in the elderly

Depression is a common clinical problem in the elderly. Risk factors in this population include genetic vulnerability, psychosocial losses, medical comorbidity, cerebrovascular disease, and neurodegenerative disorders. Depression in the elderly may have severe consequences, including high rates of suicide, malnutrition or dehydration, high utilization of medical services, impaired recovery from medical illnesses, and inappropriate placement in residential care facilities. A significant number of older depressed patients may not respond to anti-depressant medications, suffer intolerable medication side effects, or have illnesses with symptoms or consequences so severe that it is not feasible to wait the time required for one or more antidepressant trials to work. For many of these patients ECT can be a dramatically effective treatment. With appropriate evaluation and monitoring, ECT can be performed with relative safety even for patients with serious concurrent medical illnesses. Serious adverse effects are rare, and cognitive consequences of ECT are generally circumscribed and of limited duration; there is no evidence of "brain damage" or permanent change in cognitive ability from ECT. After a recovery period memory function is often better than it was during the episode of depression. For patients who have been refractory to or intolerant of medication, maintenance ECT can be an effective strategy for preventing early relapse. Further research is needed, however, to clarify the optimum use of MECT schedules and pharmacotherapy combinations to most effectively and safely prevent relapse of depression in different elderly populations and to help predict who will best respond to which treatment modalities.     

Adverse effects of medications commonly administered to thoracic surgical patients

A wide variety of medications is commonly used following thoracic surgical procedures. All of these medications have associated side effects that may adversely affect the recovery of patients. A complete understanding of the important adverse effects of all the medications used postoperatively can limit or eliminate unwanted medication effects and lead to a more successful outcome. This article will review the important actions and side effects of the most commonly administered medications following thoracic surgical procedures.     

Misuse of metered-dose inhalers: helping patients get it right

For patients who are severely impaired by obstructive lung disease, bronchodilator and anti-inflammatory medications increase airflow, enhance secretion clearance, and can potentially improve gas exchange. As a result of reduced symptoms, patients may be able to better tolerate activities of daily living and to increase endurance for activities that have personal value. Inhaled forms of these drugs, generally administered by MDI, are preferred to oral forms because they deposit directly onto the airways and cause fewer side effects. But to produce these benefits, inhaled MDIs must be used correctly. The need to evaluate MDI use by every patient, and teach correct technique when indicated, cannot be overemphasized. Metered-dose inhaler technique, practice guidelines for inhaled medications, and knowledge of inhaled medication drug classes and side effects should be required competencies for home care nurses.     

Neuroleptic-induced acute extrapyramidal syndromes and tardive dyskinesia

Neuroleptic drug-induced acute extrapyramidal symptoms and later-onset tardive dyskinesia are major limitations to these valuable drugs. Each of these disorders can be described by special risk factors that include patient characteristics, drug factors, and temporal considerations. The limitations that derive from these motor side effects have been one of the major reasons propelling the search for neuroleptic drugs that are free of these side effects. Strategies for managing the acute and late-onset extrapyramidal syndromes are presented. Significantly more research is needed, however, on all these disorders before a unified and cohesive explanation can account for these seemingly disparate syndromes. New medications, which effectively treat schizophrenia and are free of acute extrapyramidal syndromes and tardive dyskinesia, will be a giant step forward in patient care and our knowledge of the mechanisms controlling both mental function and motor control.     

The use of methylergonovine (Methergine) in the initial control of drug induced refractory headache

This study investigated the efficacy of methylergonovine maleate (Methergine) in the treatment of drug induced refractory headache (DIRH). Sixty consecutive patients (51 female and 9 male) diagnosed with DIRH were treated with methylergonovine maleate for a maximum of six months, using a within subject design. All patients were withdrawn from the medications they were taking upon entering the study. Concurrently, they were given 0.2-0.4 mg of methylergonovine maleate three times a day. Patients were provided the means to control breakthrough episodes of headache. Treatment outcome was assessed using a patient self-report scale (much better, better, same, worse, and much worse), and also visual analogue pain intensity scales. The side effects of the drug were assessed with patient self-report. Methylergonovine was effective in 44 (73%) patients. Twelve (20%) patients reported unchanged pain and 4 (6%) patients got worse. Side effects were reported by 24 patients. These were predominantly abdominal cramping. It is concluded that methylergonovine maleate is effective in the initial control of drug induced refractory headache. However, because methylergonovine is a metabolic byproduct of methysergide, the possibility or fibrotic disorders needs to be considered if methylergonovine is to be used for long term therapy.     

Treatment of cancer-related pain: when orally administered medications fail

OBJECTIVE: To summarize the available pain-relieving interventions other than oral medications for cancer-related pain. DESIGN: The pertinent literature is reviewed, and the various options for treating pain in patients with cancer are discussed. MATERIAL AND METHODS: The appropriate situations for use of parenteral administration of opioids, spinal analgesia, neural blockade, and neurosurgical treatment are outlined, and the potential problems and complications associated with these techniques are described. RESULTS: The basic approach to the management of pain in patients with cancer is to begin treatment with less potent analgesic agents early and to progress toward use of more potent pharmaceutical agents, adjuvant drugs, and invasive procedures as needed for alleviation of pain. With parenteral administration of opioids, the dosage can be adjusted rapidly, and therapy can be continued even though a patient may have gastrointestinal dysfunction. A portable ambulatory infusion pump can be used in selected patients. The major advantage of spinal opioid analgesia is the intense analgesia provided with minimal side effects. The potential complications and the availability of treatment alternatives have limited the use of neurolytic blocks, which usually provide only temporary relief of pain. In carefully selected patients with pancreatic or other upper gastrointestinal neoplasms, however, neurolytic celiac plexus and splanchnic nerve blocks are effective. Patients who fail to respond to conservative interventions may be candidates for neurosurgical procedures, such as spinal cord, cortical, or brain-stem stimulation or neuroablative operations (most commonly, cordotomy). CONCLUSION: Cancer-related pain continues to be a major problem, and clinicians should be aware of the availability of effective treatment strategies and techniques. When orally administered medications fail to control pain or cause excessive side effects, patients should be referred to an appropriate specialist or medical center for consideration of other pain-relieving techniques.     

New medical therapies in glaucoma management

New and potent medications such as alpha 2-adrenergic agonists, topically active carbonic anhydrase inhibitors, and prostaglandin analogs, are now available for use in the treatment of glaucoma. These ophthalmic medications have the potential to cause serious drug interactions and systemic side effects. The primary care physician should be able to recognize and to monitor any potential adverse effects and interact with the prescribing ophthalmologist for optimal patient care.     

Isolation and characterization of cDNA encoding chicken egg yolk aminopeptidase Ey

Twenty-five to 40 percent of patients with epilepsy continue to have seizures despite optimal treatment with traditional antiepileptic drugs. Treatment with standard anticonvulsants such as phenytoin, carbamazepine, valproic acid and phenobarbital is often complicated by side effects and by failure to adequately control seizures. Up to 61 percent of patients with seizures report having side effects with antiepileptic drugs. After a 15-year hiatus since the last new antiepileptic drug was marketed, five new drugs have been approved by the U.S. Food and Drug Administration for the control of seizures. Three of these, gabapentin, lamotrigine and topiramate, are approved for use in adults with partial seizures with or without generalization. Felbamate is approved for the above indication and also for use in children with Lennox-Gastaut syndrome, a rare childhood seizure disorder. Felbamate and lamotrigine have the potential of significant side effects and should be prescribed by physicians experienced in managing patients with complicated epilepsy. Fosphenytoin is a parenteral prodrug of phenytoin that is more tolerable than parenteral phenytoin.     

Special characteristics of psychopharmacotherapy of elderly patients

While mental disorders in the elderly can often be treated by non-medical means, suicidal ideation or agitation may require the use of psychotropic agents. Since pharmacokinetics and pharmacodynamics change with increasing age of the patient, there are a number of particular features of the use of psychotropic drugs in the elderly that urgently need to be taken into account. Geriatric patients usually require only about one-half the dose needed by younger patients, and not only the side effects of psychotropic drug treatment but also, and in particular, possible interactions with other medications must also receive appropriate consideration.     

Pharmacological prevention of relapse

Relapse is the "return of a disease after partial recovery", and is a major feature of schizophrenia disorder. It can be defined in terms of need for change in treatment, including rehospitalization or crisis intervention, the re-emergence of florid psychotic features, or gross social decompensation. Relapse is best viewed as continuum of severity rather than as discrete "attacks". Factors influencing relapse include major life events and the family constellation. Antipsychotic drugs protect against the latter but not the former, and relapse may be mediated by non-specific arousal mechanisms. The efficacy of drug treatment in postponing rather than preventing relapse is well established. The interval between relapses is prolonged at least two-fold, but in the long run most patients relapse. Unwanted effects of antipsychotic drugs can be a burden to patients, impairing quality of life. In particular, movement disorders and subjective dysphoria may be marked, as may compliance. Of these EPS, tardive dyskinesia is the most serious on long term use. Non-EPS long term effects include weight gain and endocrine changes. Depot medication has advantages over oral medication in the more ill, less compliant patients. Side effects may, however, be more marked. The greatest pain is in improved compliance but the regular supervision of the patient is also helpful. Pharmacokinetic issues are poorly understood. High and mega-dose strategies have been advocated. High doses may be needed in some patients, but megadoses are rarely justified and may be hazardous. Low dose and intermittent therapy have been evaluated but are not as successful as hoped. Some less ill patients may benefit. These schedules depend on the identification of prodromata of relapse which is not always easy, nor are relapses necessarily preceded by prodromata. Newer drugs are being developed rapidly in the search for a safer clozapine, the only antipsychotic with definitely enhanced efficacy. Other drugs which have been re-evaluated include the benzodiazepines. However, the area of greatest priority in research is that of interactions, particularly potentiation, between drug and non-drug treatments.     

Body adaptation to the action of ecological factors at the cellular and subcellular levels

While poor drug compliance is a significant impediment to the effective treatment of hypertension, knowledge of what patients wish to know about their medications in order to improve compliance is very limited. To develop a preliminary understanding of patients' medication requirements and expectations, a simple 30-item questionnaire was developed and administered to 66 patients who were either taking antihypertensive drugs, or about to commence antihypertensive drug treatment. Ninety percent of patients wanted to know about all possible side effects of medications as well as the most likely side effects. Ninety-six percent wanted to know if their drug treatment would keep them well. In addition, most patients wanted to avoid multiple medications, were concerned about the prospect of life-long treatment, and were worried about potential drug interactions. Effects of the drugs on their lifestyles as well as any lifestyle changes required to augment drug therapy were other issues of concern. The elderly were less interested in many of these issues. A strong desire for further knowledge about their disease was noted in most subjects (82%). If compliance with medication therapy is to be improved, a better understanding of patients' concerns and fears about medications is required, particularly in a relatively asymptomatic disease like hypertension.     

Multivariable feedback active structural acoustic control using adaptive piezoelectric sensoriactuators

Patients with malabsorption and histological findings consistent with celiac disease, who are unresponsive to gluten free diet, and in whom other causes of flat mucosa have been excluded, are considered to suffer from so called unclassified or refractory sprue. Although the true nature of this condition needs to be further elucidated, it is known to represent a difficult therapeutical problem with potentially fatal course. Herein, we report a patient with refractory sprue-like disease who after failing to respond to corticosteroids and TPN was in a critical condition. He responded promptly to cyclosporine and made a remarkable recovery. In contrast to previous reports, the cyclosporine treatment in this patient was pursued only for 1 month, whereupon the patient turned responsive to steroids. Subsequent treatment with azathioprine allowed corticosteroids to be reduced to a low maintenance dose and eventually all drugs could be discontinued without reappearance of symptoms. Cyclosporine therapy might be lifesaving in occasional patients with refractory sprue-like disease and it may result in reversal of steroid resistance. Moreover, azathioprine seems to have a steroid sparing effect in this setting. Short term immunosuppressive treatment may have an advantage of lower risk for drug related side effects.     

Can fish oil maintain Crohn's disease in remission?

One of the greatest challenges in managing Crohn's disease is to maintain remission. Although pharmacologic approaches to maintaining Crohn's disease in remission have significantly improved, most of the currently available modalities are associated with significant morbidity. Recently, an enteric-coated preparation of fish oil has been shown to be effective in reducing the rate of relapse in patients with Crohn's disease in remission who are at high risk of relapse. Because of minimal side effects, fish oil appears to be an ideal maintenance agent in Crohn's disease. However, until results from studies that compare the therapeutic effect of fish oil to the currently available maintenance agents are available, fish oil supplementation cannot be recommended as a sole maintenance agent at present. It does, however, seem prudent to promote a diet rich in fish oil in patients with Crohn's disease.     

Recent advances in the pharmacotherapy of schizophrenia

The limitations of standard antipsychotics have spurred a search for novel agents that are effective against both positive and negative symptoms of schizophrenia but do not produce the extrapyramidal side effects frequently associated with the older medications. Such agents might more effectively prevent relapse, because of enhanced efficacy for the full spectrum of schizophrenic symptoms and improved tolerability--and hence greater medication compliance. Findings concerning the new antipsychotics currently available, clozapine and risperidone, are reviewed, and clozapine's usefulness as a first-line treatment is evaluated. Although serious side effects and the need for weekly blood monitoring may limit clozapine's use as a first-line treatment, risperidone appears promising in this role. Preclinical and clinical studies of new antipsychotic medications recently submitted for approval (olanzapine and sertindole) or in phase III development (quetiapine and ziprasidone) are also reviewed. The findings are encouraging, and researchers hope that some of these new agents may prove valuable as first-line treatments for schizophrenia. Pharmacoeconomic studies comparing clozapine and risperidone to the standard neuroleptics indicate that these newer drugs appear likely to lower the overall cost of treatment for schizophrenia, primarily by reducing rates of relapse and rehospitalization.     

New antiepileptic drugs. Overcoming the limitations of traditional therapy

Several new antiepileptic drugs have become available recently. Since seizures and epilepsy are common, primary care physicians are likely to encounter a patient who is taking one of these new medications. Successful medical management of epilepsy requires a proper understanding of medication half-life, indications, and side effects. Felbamate has a broad spectrum of efficacy but is limited by side effects and idiosyncratic reactions. Fosphenytoin has the efficacy of phenytoin and offers the advantage of intramuscular and intravenous dosing without the significant adverse effects associated with intravenous phenytoin; however, it is expensive. Gabapentin has minimal side effects and drug interactions yet has limited efficacy for seizures. Lamotrigine has broad seizure efficacy but requires a slow adjustment to therapeutic levels. Topiramate has minimal drug interactions, but therapy must be initiated slowly to avoid side effects. All of the new antiepileptics hold great promise in the management of patients with recurrent seizures.     

Using topiramate in patients with epilepsy: practical aspects

Clinical trials are important in determining the relative efficacy and safety of a new antiepileptic drug (AED); however, experience acquired in clinical practice will eventually determine its position in the antiepileptic armamentarium. Topiramate (TPM), a new AED has been available in the United Kingdom since mid-1995 and a considerable number of patients have being treated. As a result of this experience, a number of changes have being made in the way TPM is used, particularly in the starting doses and titration rates. This seems to have improved patients' tolerability of treatment, an important consideration if a drug is to be used to its optimum level. In this article, practical tips for the use of TPM are given and these include starting doses, titration rates, options for managing side effects occurring early in treatment, advice concerning the withdrawal of concomitant AEDs and indications for discontinuation of TPM. The need for adequate patient counseling regarding potential side effects and expectations of treatment is also reviewed.     

Psychiatry today

A COMMON SITUATION: Primary care physicians often provide care for schizophrenic patients. The main approaches include drug regimens, psychotherapy and psychosocial support. DRUG THERAPY: Neuroleptics should be given in single drug regimens in a continuous protocol for long periods. Side effects, particularly neurological effects, can be countered with antiparkinson medication. The aim is to reach the best possible balance between the therapeutic effect and side effects. PSYCHOTHERAPY: The general practitioner does not necessarily use sophisticated psychotherapeutic protocols but rather relies on a certain number of attitudes aimed at helping the patient accept the medications and control the main pathological mechanisms the schizophrenic state as expressed in the relationship with the health care provider. PSYCHOSOCIAL SUPPORT: A series of assistance measures (allocations for handicapped adults, adapted housing, protection of property) often involve a team of workers who should all take part in the therapeutic strategy.     

Hepatic encephalopathy induced by flutamide administered for the treatment of prostatic cancer

Amphotericin B has been associated with multiple adverse effects; however, clinically it may be the best or only drug of choice for certain infections. This antifungal has traditionally been administered in D5W solutions over 4 to 6 hours with pre- and/or post-hydration and other medications to minimize the renal toxicity and other side effects. There have been studies using amphotericin infused in a 20% lipid emulsion with the hope of decreased side effects. By changing the diluent to lipids, the volumes to be infused over shorter periods was a challenge. This article will examine administration protocols of the D5W mixture and the lipids emulsion solution and does not advocate the use of lipid solutions.     

A medication screening tool for cognitive aging researchers.

A Web-based medication screening toll that provides researchers with information about side effects associated with medications commonly used by older participants is described. this tool can be used for research purposes to better separate the effects of normal, healthy aging processes from the deleterious effects often associated with medication usage. Researchers can use this tool, called SMART (Screening Medications: Aging Research Taxonomy), to (a) obtain information pertaining to the cognitive, sensory, and motor side effects associated with specific medications, and (b) screen medications in their research for side effect severity. The Web address for the tool is www.psychology.gatech.edu/SMART. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevention of some complications of essential hypertension

The major reason for treating hypertension is to avoid complications of the disease as it affects "target organs." Treatment of the blood pressure is not the only way to avoid these complications, but it is part of the total practice of preventive medicine. Hypertension lasts for several decades in most patients, and there is time to destroy the patient through target organ effects or to save the patient through treatment. Diabetes, atherosclerosis, and other illnesses and operations pose special hazards to the patient with hypertension. Patients take many other drugs as well, and some of them react adversely with antihypertension medicines. Complications from blood pressure drugs involve nearly every organ system, more than most physicians can remember. These may be dose-related and can often be avoided by using smaller doses of more than one drug. Certain problems occur so frequently that they should be learned well. The physician should bear in mind that whatever develops may be due to the antihypertensive therapy. On the whole, however, medications for treatment of hypertension are remarkably safe and free from side effects.