Dietary Supplement Use in Older People Attending Memory Clinics in Australia.

BACKGROUND: Dietary supplement use is common in older adults. There has been limited research in people attending memory clinics. OBJECTIVES: To explore the use of dietary supplements in older people attending Australian memory clinics. DESIGN: Cross-sectional analysis of baseline data from the Prospective Research In MEmory clinics (PRIME) study. PARTICIPANTS: Community-dwelling older people who attended nine memory clinics and had a diagnosis of mild cognitive impairment (MCI) or dementia. MEASUREMENTS: Dietary supplement was defined as a product that contains one or more: vitamin, mineral, herb or other botanical, amino acid or other dietary substance. Non-prescribed supplement was defined as a supplement that is not usually prescribed by a medical practitioner. Polypharmacy was defined as use of five or more medications. RESULTS: 964 patients, mean age 77.6 years, were included. Dietary supplements were used by 550 (57.1%) patients; 353 (36.6%) used two or more. Non-prescribed supplements were used by 364 (36.8%) patients. Supplement use was associated with older age (OR: 1.12, 95% CI: 1.03-1.21), lower education level (OR: 1.53, 95% CI: 1.01-2.32) and a diagnosis of MCI rather than dementia (OR: 1.52, 95% CI: 1.05-2.21). Potential drug-supplement interactions were identified in 107 (11.1%) patients. Supplement users had increased prevalence of polypharmacy compared to non-users (80.5% vs. 48.1%, p<0.001). CONCLUSIONS: Dietary supplements, including non-prescribed supplements, were commonly used by people attending memory clinics. Supplement use increased the prevalence of polypharmacy and resulted in potential supplement-drug interactions. Further research is required to assess the clinical outcomes of supplement use.

The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers.

OBJECTIVE: To investigate if a lower dose of arginine in the form of an oral nutritional supplement can show similar benefit in the healing rate of pressure ulcers compared with the current evidence for 9g of arginine. METHOD: Twenty-three inpatients with category II, III or IV pressure ulcers were randomised to receive daily, for 3 weeks, the standard hospital diet plus 4.5 or 9g arginine in the form of a commercial supplement. Pressure ulcer size and severity was measured weekly (by PUSH tool; pressure ulcer scale for healing; 0= completely healed, 17= greatest severity). Nutritional status was determined by Subjective Global Assessment. RESULTS: There were no significant differences in patients' age, gender, BMI, haemoglobin levels, albumin levels and diagnosis of diabetes between treatment groups. There was a significant decrease in pressure ulcer severity over time (p < 0.001), with no evidence of a difference in healing rate between the two arginine dosages (p=0.991). Based on expected healing time, patients in both treatment groups were estimated to achieve an almost 2-fold improvement compared with the historical control group. Patients categorised as malnourished showed clinically significant impaired healing rates compared with well nourished patients (p=0.057), although this was unaffected by arginine dosage (p=0.727). CONCLUSION: Similar clinical benefits in healing of pressure ulcers can be achieved with a lower dosage of arginine, which can translate into improved concordance and significant cost-savings for both the health-care facilities and for patients.

Polypharmacy management among Australian veterans: improving prescribing through the Australian Department of Veterans' Affairs' prescriber feedback programme.

BACKGROUND: Older patients are potentially at risk from the effects of polypharmacy (PP) and/or drug-drug interactions. AIMS: To examine the effects of a targeted patient-specific prescriber feedback programme on patients prescribed more than 19 individual medications over the 3-month study period. METHODS: The Commonwealth Department of Veterans' Affairs commissioned a review of Repatriation Pharmaceutical Benefit Scheme claims data to identify patients potentially at risk of drug injury through either PP (> or =20 unique medications during 3 months) or clinically significant drug interactions (DI). Dispensing information for the patient at risk, relevant clinical guidelines and a personalized covering letter were mailed to the main prescribing general practitioner of the identified veteran patient. The claims data were then re-analysed after the programme. RESULTS: There was a significant reduction in the mean number of unique medications prescribed over a 3-month period 1 year after the prescriber feedback (mean change = -2.22; 95% confidence interval -3.54 to -0.90; P = 0.0013) for patients identified with ongoing PP. There was also a significant reduction in the number of DI pairs (mean change = -0.73; 95% confidence interval -0.77 to -0.69; P < 0.0001) for the patients identified with an ongoing DI. The number of patients dispensed one or more DI pairs decreased from 836 to 318 after the feedback. CONCLUSION: A targeted prescriber feedback programme can influence general practitioner prescribing at an individual patient level and, therefore, contribute to the quality use of medicines.

Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback.

BACKGROUND: Benzodiazepines are commonly prescribed for older people. Inappropriate benzodiazepine prescribing may result in serious adverse effects, including confusion and falls. AIMS: To determine the prevalence and appropriateness of benzodiazepine prescribing for elderly inpatients at nine public hospitals in Victoria, Australia, and to assess the impact of multidisciplinary feedback on quality of benzodiazepine prescribing. METHODS: Clearance for the study was obtained from ethics committees of participating hospitals. Medication charts for 1301 patients aged 65 years and over were reviewed to identify patients prescribed a benzodiazepine. Using an evidence-based indicator of prescribing appropriateness, cross-sectional notes-based audits were conducted at three time points (baseline, 4-8 weeks and 6 months). Feedback of baseline audit results was provided to medical, pharmacy and nursing staff at multidisciplinary meetings. Changes in benzodiazepine prescribing over the following 6 months were assessed. RESULTS: At baseline, benzodiazepines were prescribed for 36% of patients, and 20% of prescriptions were appropriate. Four to six weeks after feedback, the proportion of patients prescribed a benzodiazepine had not changed significantly (31%, P = 0.125); however, more prescriptions were appropriate (44%, P < 0.0001). For patients who were using a benzodiazepine prior to admission and had a contraindication, there were more attempts to withdraw or reduce the dose (47% vs 21%, P = 0.002) and more prescriptions were for acceptable indications (7.4% vs 2.6%, P = 0.024). Six months after feedback, appropriateness of prescribing remained improved compared with baseline (50%, P = 0.002). CONCLUSIONS: Benzodiazepines were prescribed for approximately one in three elderly hospital inpatients and a large proportion was inappropriate. A multidisciplinary intervention based on audit and feedback improved prescribing and the impact of the intervention was still evident after 6 months.

Response of parkinsonian swallowing dysfunction to dopaminergic stimulation.

OBJECTIVES: To determine the degree of dopaminergic response of swallowing dysfunction in Parkinson's disease. METHODS: Fifteen patients with idiopathic Parkinson's disease and symptomatic dysphagia were studied. All had motor fluctuations in response to long term levodopa therapy. On two separate days, after overnight withdrawal of all antiparkinsonian medication, a modified barium swallow using cinefluoroscopy and different food consistencies was performed before and after administration of oral levodopa and subcutaneous apomorphine. RESULTS: Despite all patients having an unequivocal motor response to both agents, there were few significant responses in any of the quantitative or qualitative criteria of swallowing dysfunction assessed. The oral preparatory phase, generally considered a more voluntary component of swallowing, showed a response, but not with all consistencies. In a subgroup of patients the pharyngeal phase time also improved. CONCLUSIONS: These findings suggest that parkinsonian swallowing dysfunction is not solely related to nigrostriatal dopamine deficiency and may be due to an additional non-dopamine related disturbance of the central pattern generator for swallowing in the pedunculopontine nucleus or related structures in the medulla.

Asymptomatic swallowing disorders in elderly patients with Parkinson's disease: a description of findings on clinical examination and videofluoroscopy in sixteen patients.

We sought to ascertain whether patients with Parkinson's disease without symptoms of dysphagia have abnormalities of swallowing, and to describe the characteristics as seen on clinical examination and videofluoroscopy. Patients with stable Parkinson's disease were interviewed for symptoms of dysphagia and 16 asymptomatic patients were enrolled. Whilst on their usual medication, an examination of facial, tongue and palatopharyngeal musculature was made, and a modified barium swallow performed. All patients had at least one abnormality on videofluoroscopic examination of their swallowing. Three patients showed aspiration and 14 had evidence of vallecular residue considered a risk for aspiration. Oropharyngeal transit time was invariably prolonged as was delay in the initiation of swallow. The majority of patients also demonstrated an increased number of tongue elevations and number of swallows to clear their pharynx of the bolus. Despite having no symptoms of dysphagia, the patients demonstrated widespread abnormalities of swallowing.