Patrick R. Montgomery

Drug-associated hospital admissions in older medical patients.

A survey of drug‐related admissions of patients aged 50 years and older was conducted at the Health Sciences Centre, Winnipeg to determine the interrelationship of risk factors, and isolate the effect of age. All nonelective medical admissions were prospectively assessed to determine the role of drug therapy as a contributory factor. Of the 863 eligible admissions, 162 exhibited at least one drug‐related adverse patient event (DRAPE) at the time of hospitalization. This accounted for 19% of the admissions (23% of 718 admissions that involved prescription drugs). Although adverse drug reactions were responsible for many DRAPEs (48%), intentional noncompliance (27%), treatment failure (19%), alcohol (14%), and medication error (10%) were also frequent contributing causes. Drugs commonly implicated in DRAPEs were systemic steroids, digoxin, nonsteroidal anti‐inflammatory agents, α‐methyldopa, calcium channel blockers, β‐blockers, theophylline, furosemide, sympathomimetics, thiazides, and benzodiazepines. The risk of a DRAPE was related to the number of diseases prior to admission (r = 0.81; P < .026) and the number of drugs used (r = 0.77; P < .001). Age was not correlated with the risk of a DRAPE. Females had significantly more adverse drug reactions, although sex was not a predictor for overall DRAPE risk.

Pill Count, Self-Report, and Pharmacy Claims Data to Measure Medication Adherence in the Elderly

OBJECTIVE: To compare medication adherence calculated from four different data sources including a pill count and self-report obtained during a home medication history, as well as calculations based on refill frequency derived from a provincial prescription claims database (manual and electronic). DESIGN: Baseline medication adherence was collected as part of a prospective, randomized, controlled study. Mean medication adherence results obtained from the four data sources were compared using repeated-measures ANOVA followed by a Tukeys multiple range test. SETTING: A pharmacy consultation service located at an interdisciplinary wellness center for noninstitutionalized elderly. PATIENTS: 65 years or older, noninstitutionalized, taking one or more prescribed or nonprescribed medications. Clients would either present to the wellness center or be referred by the Provincial Home Care program. RESULTS: When calculated from self-report or manual or electronic prescription claims data, mean percent adherence by drug was high and not statistically different (95.8% ± 17.1%, 107.6% ± 40.3%, and 94.6% ± 24.0%, respectively), whereas the pill count adherence was significantly lower at 74.0% ± 41.5% (p < 0.0001). CONCLUSIONS: An unexpected finding was that the pill count technique used in this study of elderly clients using chronic, repeat medications appeared to underestimate medication adherence. Numerous other limitations of pill count, self-report, and a province-wide prescription claims database in estimating medication adherence are presented. When using medication adherence as a process measure, the researcher and practitioner should be aware of the limitations unique to the data source they choose, and interpret data cautiously.

The Diagnosis of “Mixed” Dementia in the Consortium for the Investigation of Vascular Impairment of Cognition (CIVIC)

Abstract: If vascular risk factors are risks for Alzheimers disease (AD), and if “pure” vascular dementia (VaD) is less common than has been thought, what do we make of the diagnosis of mixed dementia? We report characteristics of those with mixed dementia in a prospective, seven center, clinic‐based Canadian study.

The Consortium to Investigate Vascular Impairment of Cognition: methods and first findings.

BACKGROUND The Consortium to Investigate Vascular Impairment of Cognition (CIVIC) is a Canadian, multi-centre, clinic-based prospective cohort study of patients with Vascular Cognitive Impairment (VCI). We report its organization and the impact of diagnostic criteria on the study of VCI. METHODS Nine memory disability clinics enrolled patients and recorded their usual investigations and care. A case report form included all vascular dementia (VaD) individual criteria for each of four sets (National Institute of Neurological Disorders and Stroke (NINDS-AIREN), Alzheimers Disease Diagnostic Treatment Centers (ADDTC), the ICD-10 Classification of Mental and Behavioural Disorders (ICD-10), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)) of consensus-based diagnostic criteria and for the Hachinski Ischemia Score (HIS). Investigators, having completed the case report form, were asked to make a clinical judgement about the cognitive diagnosis based on the best available information, including neuroimaging. RESULTS Of 1,347 patients (mean age 72 years; 56% women), 846 (63%) were diagnosed with dementia and 324 (24%) were diagnosed with VCI. The proportion of patients diagnosed with VaD by the diagnostic criteria was: 23.9% (n = 322) by DSM-IV, 10.2% (n = 137) by HIS, 4.3% (n = 58) by ICD-10, 3.8% (n = 51) by ADTCC, and 3.6% (n = 48) by NINDS-AIREN. Judged against a clinical diagnosis of VaD, the sensitivity/specificity of each was: DSM-IV (0.77/0.80); HIS (0.41/0.92); ICD-10 (0.29/0.98); ADTCC (0.24/0.98); NINDS-AIREN (0.42/0.995). Compared with a clinical diagnosis of VCI, sensitivities were lower for the diagnostic criteria, reflecting the exclusion of patients who did not have dementia. CONCLUSIONS Consensus-based criteria for VaD omit patients who do not meet dementia criteria that are modeled on Alzheimers disease. Even for patients who do, the proportion identified with VaD varies widely. Criteria based on empirical analyses need to be developed and validated.

Salicylate metabolism: Effects of age and sex in adults

The plasma concentrations and urinary excretion rates of salicylic acid (SA) and some of its metabolites (salicyluric acid [SUA] and acyl and phenolic glucuronide conjugates) were measured after an oral dose of acetylsalicylic acid to 44 healthy subjects of both sexes 20 to 78 years old. There was no change in the SA absorption rate, and plasma clearance of SA was not affected by age or sex. The volume of distribution increased with age in men but not in women. Plasma concentrations of SUA rose with age as the renal clearance of this metabolite fell. The kinetic parameters Km and Vmax for the SA‐to‐SUA reaction did not change with age; Vmax was significantly higher in women than in men. Urinary recovery of SA and its metabolites essentially accounted for the administered dose, and was little influenced by age or sex. We conclude that these factors play a minor role in the disposition of salicylate.

Impact of a pharmaceutical care model for non-institutionalised elderly: results of a randomised, controlled trial

Objectives — To measure the impact of a community‐based geriatric pharmaceutical care model on specific process measures.

Cognitive impairment and life satisfaction in older adults

Quality of life in dementia has been studied in clinical settings. There is less population‐based research on life satisfaction and cognition.

Marital status, partner satisfaction, and depressive symptoms in older men and women.

Objectives: To determine if marital status is associated with depressive symptoms in men and women, and to determine if partner satisfaction is associated with depressive symptoms. Methods: Community-dwelling adults (n = 1751) aged 65 years and older were sampled from a representative population-based registry. Age, sex, education, and marital status were self-reported. Satisfaction with living partner was assessed with an item from the terrible-delightful scale. The Center for Epidemiologic Studies—Depression was used to assess depressive symptoms, with a score of 15 or more indicating depressive symptoms. Results: Only 3% of the sample were dissatisfied with their living partner, and those who were dissatisfied with their living partner had higher levels of depressive symptoms. Proportions of men with depressive symptoms were: 20.6% for never married; 19.2% for separated or divorced; 17.3% for widowed; 7.3% for married (satisfied); and 38.1% for married (dissatisfied) (χ2 = 32.98, df = 4, P < 0.001). In women, the results were different: 11.8% for never married; 23.1% for separated or divorced; 15.4% for widowed; 14.4% for married (satisfied); and 41.9% for married (dissatisfied) (χ2 = 18.33, df = 4, P < 0.001). In logistic regression models, a significant interaction term was seen for Marital status x Sex. In stratified models, adjusting for age and education, an effect of marital status was seen in men, but not in women. Conclusions: The effects of marriage on depressive symptoms in men and women may be different, with lower levels of depressive symptoms in married men, compared with unmarried men, but similar rates in married women, compared with unmarried women. Dissatisfaction with their partner was uncommon, but highly associated with depressive symptoms.

Clinical and radiographic subtypes of vascular cognitive impairment in a clinic-based cohort study

BACKGROUND AND PURPOSE There is a need for empirical studies to define criteria for vascular cognitive impairment (VCI) subtypes. In this paper, we report the predictive validity of a subtype classification scheme based on clinical and radiographic features. METHODS Nine Canadian memory clinics participated in the Consortium to Investigate Vascular Impairment of Cognition. This cohort consisted of 1347 patients, of whom 324 had VCI, and was followed for up to 30 months. RESULTS Clinical and neuroimaging features defined three subtypes: vascular cognitive impairment, no dementia, (n=97), vascular dementia (n=101) and mixed neurodegenerative/vascular dementia (n=126). Any ischemic lesion on neuroimaging increased the odds (odds ratio=9.31; 95% confidence interval 6.46, 13.39) of a VCI diagnosis. No VCI subtype, however, was associated with a specific neuroimaging abnormality. Compared to those with no cognitive impairment, patients with each VCI subtype had higher rates of death and institutionalization (hazard ratio for combined adverse events=6.08, p<0.001). CONCLUSIONS Both clinical features and radiographic features help establish a diagnosis of VCI. The outcomes of VCI subtypes, however, are more strongly associated with clinical features than with radiographic ones.

Disease progression in vascular cognitive impairment: cognitive, functional and behavioural outcomes in the Consortium to Investigate Vascular Impairment of Cognition (CIVIC) cohort study.

BACKGROUND AND PURPOSE Empirical studies to clarify the outcomes in Vascular Cognitive Impairment (VCI) are needed. We compared cognitive, functional, and behavioural outcomes in patients with VCI to patients with no cognitive impairment (NCI), and Alzheimers disease (AD). METHODS Secondary analysis of the Consortium to Investigate Vascular Impairment of Cognition (CIVIC), a multi-centre Canadian memory clinic 30-month cohort study. RESULTS Of 1347 patients, 938 were eligible for follow-up, of whom 239 (24.5%) were lost and 29 (3%) had died. Of the remaining 697 patients, 125 had NCI, 229 had VCI, and 343 had AD at baseline. Compared to people with NCI, of whom 20-40% showed progression based on cognitive and functional measures, those with VCI were more likely to progress (50-65%), as were people with AD (50-80%) (p<0.01). More people with VCI showed progression of affective symptoms (30%) than those with NCI (12%) or AD (15% p<0.01). Progression of impaired judgment (rated clinically) in VCI (15%) was similar to AD (11%) but more common than in NCI (4%, p<0.01). CONCLUSIONS Most people with VCI show readily detectable progression by 30 months. Depressive symptoms were more common and more progressive in VCI than in Alzheimers disease, whereas clinical evidence of progressive executive dysfunction was common in both AD and VCI.