Anticholinergic Burden in Geriatric Patients Attending Clinical Pharmacology Clinic — A Descriptive Cross-sectional Study in Eastern India

Background : Anticholinergic burden in Geriatric population is of great concern throughout the Globe, yet often neglected. There are previous studies to assess the Anticholinergic burden, carried out in specific population, though its prevalence in general population is difficult to interpret. Polypharmacy remains one of the major causes contributing to the increased burden in Anticholinergic score among Geriatrics. Multiple co-morbidities and the prevalence of Multiple Chronic Diseases are the responsible factors which imbibe Multiple Drug Therapy in Geriatric population. Anticholinergic burden in older adults has been associated with Cognitive impairment, Delirium, Dizziness and Confusion, Falls and increased hospitalizations. However, Anticholinergic-acting drugs are often advised in Geriatric population. In this study an attempt was made to understand the Anticholinergic burden score among Geriatric population. Methods : This study is a descriptive cross-sectional study, which was done, in a period of six months among 62 Geriatric patients attending a therapeutics clinic of a private clinical pharmacology OPD for first time. Patients were noted for their comorbidities and anticholinergic burden was calculated, based on the Anticholinergic Cognitive Burden scale. Results were statistically analyzed. Results : Clinically significant anticholinergic burden was observed in 22.58% population. The most frequently prescribed drug was found to be alprazolam followed by amitriptyline and theophylline. Among the comorbidities hypertension and diabetes was commonly seen in majority of the population. Conclusion : Co-professional care at clinical pharmacology OPD with assessment of anticholinergic burden of geriatric prescriptions and advices on rational de-prescribing with suggestions on safer alternatives would be beneficial for treating physicians to optimize therapy.

Indian Reality of Clinical Practice and Patient Profile in Diabetes Care: Lessons from the IMPACT survey

India shoulders a heavy burden of diabetes mellitus (DM), the management of which is suboptimal globally. Objectives: Insulin Management: Practical Aspects in Choice of Therapy (IMPACT) survey was designed to gain insight into the ground (in-clinic) reality of DM management by physicians in India. Methods: A survey consisting of 12 multiple-choice questions was conducted by SurveyMonkey ® , focusing on practice profile, patient profile, and other aspects of DM management. Results: The survey included 2424 physicians. Majority of them were general physicians (58.5%) followed by diabetologists (31.1%). Most (49.2%) of the respondents specified that the ideal time for a DM consultation is 15 min. However, 73.4% of them provided consultation of <10 min because of heavy patient load. Nearly half of the respondents reported that their patients consumed a diet with carbohydrate content of 60% to 80%, and 79.4% of them admitted that <50% of their patients adhered to dietary advice. About 73.5% of the respondents believed controlling fasting plasma glucose (FPG) level alone would not adequately control postprandial plasma glucose (PPG) level, and 93.0% of them preferred an insulin therapy at the initiation that controls both FPG and PPG levels. Conclusion: Limited consultation time, high-carbohydrate diet, and a need for choosing insulin regimens that provide control for both PPG and FPG levels are some ground realities of DM management in India. These realities need to be factored in while choosing treatment options to achieve the desired glycemic control and improve the status of diabetes care.

Prevalence of generalized & abdominal obesity in urban & rural India- the ICMR-INDIAB study (Phase-I) [ICMR-INDIAB-3].

Background & objectives: Overweight and obesity are rapidly increasing in countries like India. This study was aimed at determining the prevalence of generalized, abdominal and combined obesity in urban and rural India. Methods: Phase I of the ICMR-INDIAB study was conducted in a representative population of three states [Tamil Nadu (TN), Maharashtra (MH) and Jharkhand (JH)] and one Union Territory (UT)[Chandigarh (CH)] of India. A stratified multi-stage sampling design was adopted and individuals ≥20 yr of age were included. WHO Asia Pacific guidelines were used to define overweight [body mass index (BMI) ≥23 kg/m2 but <25 kg/m2], generalized obesity (GO, BMI≥25kg/m2), abdominal obesity (AO, waist circumference ≥90 cm for men and ≥80cm for women) and combined obesity (CO, GO plus AO). Of the 14,277 participants, 13,800 subjects (response rate, 96.7%) were included for the analysis (urban: n=4,063; rural: n=9737). Results: The prevalence of GO was 24.6, 16.6, 11.8 and 31.3 per cent among residents of TN, MH, JH and CH, while the prevalence of AO was 26.6, 18.7, 16.9 and 36.1 per cent, respectively. CO was present in 19.3, 13.0, 9.8 and 26.6 per cent of the TN, MH, JH and CH population. The prevalence of GO, AO and CO were significantly higher among urban residents compared to rural residents in all the four regions studied. The prevalence of overweight was 15.2, 11.3, 7.8 and 15.9 per cent among residents of TN, MH, JH and CH, respectively. Multiple logistic regression analysis showed that female gender, hypertension, diabetes, higher socio-economic status, physical inactivity and urban residence were significantly associated with GO, AO and CO in all the four regions studied. Age was significantly associated with AO and CO, but not with GO. Interpretation & conclusions: Prevalence of AO as well as of GO were high in India. Extrapolated to the whole country, 135, 153 and 107 million individuals will have GO, AO and CO, respectively. However, these figures have been estimated from three States and one UT of India and the results may be viewed in this light.

Clinical profile of adrenoleukodysrophy.

X-linked Adrenoleukodystrophy (ALD) is the most common of the peroxisomal disorder and is associated with functional defect of the very long chain fatty acid (VLCFA) oxidation leading to the accumulation of VLCFA in the white matter and adrenal cortex. Retrospective evaluation of medical records of ALD patients were carried out. In all the 5 patients the duration of the symptoms varied from 1-7 years. Most of them presented with Addisonian crisis (4/5) and hyperpigmentation (5/5), white half of them (3/5) had neurological symptoms. All patients had biochemical evidence of the adrenal insufficiency. All siblings of patients should be screened for the possibility of ALD with VLCFA.

Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for asian indians and recommendations for physical activity, medical and surgical management.

Asian Indians exhibit unique features of obesity; excess body fat, abdominal adiposity, increased subcutaneous and intra-abdominal fat, and deposition of fat in ectopic sites (liver, muscle, etc.). Obesity is a major driver for the widely prevalent metabolic syndrome and type 2 diabetes mellitus (T2DM) in Asian Indians in India and those residing in other countries. Based on percentage body fat and morbidity data, limits of normal BMI are narrower and lower in Asian Indians than in white Caucasians. In this consensus statement, we present revised guidelines for diagnosis of obesity, abdominal obesity, the metabolic syndrome, physical activity, and drug therapy and bariatric surgery for obesity in Asian Indians after consultations with experts from various regions of India belonging to the following medical disciplines; internal medicine, metabolic diseases, endocrinology, nutrition, cardiology, exercise physiology, sports medicine and bariatric surgery, and representing reputed medical institutions, hospitals, government funded research institutions, and policy making bodies. It is estimated that by application of these guidelines, additional 10-15% of Indian population would be labeled as overweight/obese and would require appropriate management. Application of these guidelines on countrywide basis is also likely to have a deceleration effect on the escalating problem of T2DM and cardiovascular disease. These guidelines could be revised in future as appropriate, after another large and countrywide consensus process. Till that time, these should be used by clinicians, researchers and policymakers dealing with obesity and related diseases. ©

Whole grains and health: Perspective for Asian Indians.

Grains are a part of human diet for about 10,000 years . Grains are the most important food source of Indian population, due to this carbohydrate consumption constitute approx. 60-70% of total food intake. Variety of grains are available in India , and different grains form staple diets of people in different part of the country. Whole grains are now recognized as an important source of fiber and other nutrients like trace minerals a vitamins. Grains have shown to have a role in prevention and reducing the risk of Type 2 Diabetes, Coronary Heart Disease, Cancer and Obesity. ©

Vitamin D status in India – Its implications and remedial measures.

Vitamin D deficiency is epidemic in India despite of plenty of sunshine. The interpretation of vitamin D levels should be done with the solar zenith angle, minimal erythemal dose, skintype, UV Index and geographical location. All Indian studies uniformly point to low 25(OH)D levels in the populations studies despite abundant sunshine. All studies have uniformly documented low dietary calcium intake compared to Recommended Daily/Dietary Allowances (RDA) by Indian Council of Medical Research (ICMR). The vitamin D status of children is very low in both urban and rural population studied. Pregnant women and their new born had low vitamin D status. The effect of short course of loading doses of vitamin D doesn’t have a lasting effect and a maintenance dose is needed. Low 25(OH)D levels has its implications of lower peak bone mass and lower BMD compared to west. There may be a public health need to fortify Indian foods with vitamin D. ©

Hyponatremia and hypernatremia: disorders of water balance.

Total body water and tonicity is tightly regulated by renal action of antidiuretic hormone (ADH), reninangiotensin-aldosterone system, norepinephrine and by the thirst mechanism. Abnormalities in water balance are manifested as sodium disturbances--hyponatremia and hypernatremia. Hyponatremia ([Na+ < 136 meq/ l]) is a common abnormality in hospitalized patients and is associated with increased morbidity and mortality. A common cause of hyponatremia is impaired renal water excretion either due to low extracellular fluid volume or inappropriate secretion of ADH. Clinical assessment of total body water and urine studies help in determining cause and guiding treatment of hyponatremia. Acute and severe hyponatremia cause neurological symptoms necessitating rapid correction with hypertonic saline. Careful administration and monitoring of serum [Na+] is required to avoid overcorrection and complication of osmotic demyelination. Vasopressin receptor antagonists are being evaluated in management of euvolemic and hypervolemic hyponatremia. Hypematremia ([Na+] > 145 meq/l) is caused by primary water deficit (with or without Na+ loss) and commonly occurs from inadequate access to water or impaired thirst mechanism. Assessment of the clinical circumstances and urine studies help determine the etiology, while management of hypernatremia involves fluid resuscitation and avoiding neurological complications from hypernatremia or its correction. Frequent monitoring of [Na+] is of paramount importance in the treatment of sodium disorders that overcomes the limitations of prediction equations.

An epidemiological review of mobile telephones and cancer.

Mobile telecommunication technology became commercially available about 20-25 years ago in different countries around the world. The industry has grown exponentially over the years and, currently, the number of mobile phone users is estimated to be over 3.8 billion, more than half the world's population. Thus, because of such a large population-at-risk, any health hazard from these devices promises to have a large epidemiological impact. Intense speculation and investigation into the relationship between mobile phone usage and cancer has led to the publication of numerous, often contradictory, reports on this subject. This review aims to provide a large body of reported evidence to help medical professionals disseminate evidence-based information to their patients.

Health hazards of mobile phones: an Indian perspective.

The mobile phone industry has been one of the fastest growing industries in modern history. Today, India has million mobile phone users, and mobile phones account for 88% of all telecommunication users. The rural sector accounts for more than 25% of all wireless phone users and this proportion is bound to grow as affordability of mobile phones continues to increase. In the years ahead, an ever-increasing number exposed for long periods of time to radiation from mobile phones. In 2008, the Telecom Commission (the policy-making body of the Department of Telecommunicatics, Government of India) adopted the emission guidelines prescribed by the International Commission on Non-Protection (ICNIRP). Studies have demonstrated that usage behaviours, such as duration of usage and predominant, one-sided use of mobile phones are some of the chief risks that increase likelihood of hazards resulting from mobile phone use. This article attempts to present the basic biophysics of these devices and explain the health hazards of electromagnetic radiation exposure in terms of thermal and non-thermal effects. We also present some preventive measures that can reduce the risk of these hazards.

Disorders of potassium homeostasis: pathophysiology and management.

Disorders of potassium homeostasis are common electrolyte abnormalities encountered in hospitalized patients. Hypokalemia and hyperkalemia have been estimated to occur in about 21% and 3% of hospitalized patients, respectively; though the morbidity and mortality associated with the latter is significantly higher. Potassium is a predominantly intracellular ion and the understanding of its dynamics between intra- and extracellular fluid milieus, along with its handling by the kidneys, is important in the diagnosis and treatment of potassium disorders. This article aims to provide a clinically relevant update on management of potassium disorders for internists.

Disorders of calcium, phosphorus and magnesium metabolism.

Abnormalities of calcium, magnesium and phosphorus are common in hospitalized patients. Infrequently patients might present in the outpatient settings with non-specific symptoms that might be due to abnormalities of divalent cation (magnesium, calcium) or phosphorous metabolism. Several inherited disorders have been identified that result in renal or intestinal wasting of these elements. Physicians need to have a thorough understanding of the mechanism of calcium, magnesium and phosphorous metabolism and diagnoses disorders due to excess or deficiency of these elements. Prompt identification and treatment of the underlying disorders result in prevention of serious morbidity and mortality.

Inter-generation comparison of type-2 diabetes in 73 Indian families.

AIMS AND OBJECTIVE: To study type 2 diabetics in 2 generations in the same family and to see if there are any significant differences in their presentations. The study also focused on the non-diabetic siblings to see if there were any differences between them. MATERIAL AND METHODS: Criteria for inclusion: 1. Proband case should have a parent who is a diabetic, 2. Proband case should have at least one sibling who is not diabetic. Entire families of such cases fulfilling the above criteria were included in the study. A detailed questionnaire was filled. This was followed by an examination of all anthropometric measurements like height, weight, waist circumference, hip circumference and blood pressure. Venous blood samples for glucose measurement (fasting and post prandial), HbA1c, renal profile, lipid profile and insulin levels were collected. Urine sample was collected in appropriate containers for microalbuminuria, albumin/creatinine ratio. RESULTS: The study included 73 families, with a total of 307 members (159 male and 148 female). 92 were from 1st generation and 215 from 2nd generation. Of these 182 were diabetics, 81 from 1st generation and 151 from 2nd generation (95 males and 87 females). 125 were non diabetics, 9 from 1st generation and 116 from the 2nd generation (64 males and 61 females). The mean age of onset of diabetes in 1st generation was 55.95 years (SD +/- 9.98) and in 2nd generation was 38.4 years (SD +/- 9.2) (p<0.0001). Body mass index (BMI), waist circumference, Wasist-hip ratio (W/H ratio) and triglycerides, HDL and blood pressure individually did not show any significant differences between the diabetics in both generations. The incidence of metabolic syndrome as per ATPIII criteria was 75.9 % among the 1st generation diabetics. There were only 9 non-diabetics in the first generation and this number was small to derive any statistical significance. Comparison between diabetics and non diabetics in the 2nd generation showed that the incidence of metabolic syndrome as per ATPIII criteria was significantly higher among the diabetics at 62.63% as against 28.45% in the non diabetics. BMI, W/H ratio and lipid profile individually did not show any significant differences between the diabetics and non diabetics. CONCLUSIONS: This study shows that the age of onset of diabetes is much earlier in the present generation being 38.4 years (SD +/- 9.2), as compared to 55.95 years (SD +/- 9.98) in the previous generation. There were no other significant differences between the two generations. In the present generation the incidence of metabolic syndrome as per ATPIII criteria was a significant risk factor for the development of diabetes. 62.63% of the diabetic siblings had metabolic syndrome as compared to 28.45% in the nondiabetic siblings. There were no other significant parameters for early detection of diabetes in this group.

Challenges in diabetes care in India: sheer numbers, lack of awareness and inadequate control.

With an estimated 40 million people suffering from the condition, the largest in any country in the world, diabetes has become a major health care problem in India. Recent epidemiological studies from India point to the great burden due to diabetes and its micro and macrovascular complications. This is primarily because the status of diabetes control in India is far from ideal. Based on the available data, the mean glycated hemoglobin levels are around 9% which is at least 2% higher than the goal currently suggested by international bodies. The IMPROVE study has helped identify the barriers to good control of diabetes both among patients as well as physicians in today's practice. However the recent ACCORD study points to the dangers of overaggressive treatment, especially in high risk in elderly patients. A balanced approach to improve awareness about diabetes and its control both among patients and the medical fraternity is urgent need of the hour in India. The associated risks of tight control in high risk groups should also be kept in mind.