LETTERS TO THE EDITOR
JAGS-IANUARY 1991-VOL. 39 NO. I
103
slightly greater in patients older than 70 years though the sinusitis and a closed head injury with bifrontal and biparietaI difference from younger ones did not reach statistical signif- contusions 5 years prior to the onset of anorexia; the anorexia icance (45% vs 41%). In the extensive group of patients did not correlate with exacerbations of sinusitis. He denied studied, we failed to show any relationship between ad- depression, slept well, and participated in recreational activivanced age and prognosis of ARF, in agreement with other ties. A trial of cyproheptadine, 4 mg tid, was ineffective as a ~ t h o r s . Prognosis ~-~ depended on the complications arising were aggressive treatment of sinusitis with antibiotics and an during the ARF episode. Four risk factors were found to be empirical trial of nortriptyline, 50 mg qhs. The latter was significantly related to mortality: need for dialysis, coma, discontinued, and chlorpromazine 25 mg bid was started. mechanical respiration, and hypotension. Deep neurological Within 48 hours the patient began to eat most or all of the coma was especially ominous; only 18% of those with this food that was presented to him. Choreiform movements were complication survived. Mortality was significantly higher in essentially unchanged. The patient has been successfully older patients requiring dialysis than in younger ones (79% maintained on this medication for 3 months and has regained vs 57%, p < 0.05). Mortality rates related to the other prog- 20 pounds. Anorexia is quite unusual in Huntington's disease; indeed, nostic factors were not different on the basis of age. Elderly patients who survived an ARF episode needed most patients are described as voracious eaters, possibly due more time for total recovery than younger people (11 days to increased caloric demand.',* It is possible that the patient's vs 7 days, p < 0.05, in pre-renal episodes and 22 days vs 19 head injury or the sinusitis might be related to the anorexia. days, NS, in acute tubular necrosis). Interestingly, all survi- This underscores the unfortunate reality that the etiology of vors recovered enough renal function to be removed from anorexia in such patients is frequently never determined. Most neuroleptics cause a degree of weight gain, chlordialysis. This was true in both age groups, in disagreement especially SO.^ The mechanism for this is not clear. with previous reports that age is a determinant for r e ~ o v e r y . ~ ,promazine ~ Age should not be used as a discriminant factor in therapeutic Chlorpromazine has a strong affinity for serotonergic recept o r ~ and , ~ serotonin blockade has been strongly associated decisions concerning ARF. with appetite stimulation in both animals and man! We are generally reluctant to treat debilitated and elderly J. PASCUAL, MD L. OROFINO, MD patients with chlorpromazine due to its high incidence of F. LIAKIo, MD postural hypotension. However, this may not be problematic R. MARC&,MD in bedridden or non-ambulatory patients. The risk of tardive L. ORTE,MD dyskinesia must of course be borne in mind in such patients J. ORTUKIO, MD as well. Aside from this, chlorpromazine is relatively well Nephrology Department tolerated and may also have the added benefit of treating Hospital Rambn y Cajal agitation or psychosis in certain patients. Thus, when used Madrid, Spain with caution, chlorpromazine may be a reasonable option for appetite stimulation in selected patients. ALANJ. WALDMAN, MD T. STEWART, MD Assistant Professor in Psychiatry University of Florida College of Medicine Gaines.de, FL
REFERENCES
JONATHAN
1. Roy AT, Johnson LE, Lee DBN, et al: Renal failure in older
people. UCLA Grand Rounds. J Am Geriatr SOC38:239,1990 2. Pascual J, Orofino L, Liaiio F, et al: Incidence and prognosis of acute renal failure in older patients. J Am Geriatr SOC38:25, 1990 3. Kumar R, Hill CM, McGeown MG. Acute renal failure in the elderly. Lancet 1:90, 1973 4. Lameire N, Matthys E, Vanholder R, et al. Causes and prognosis of acute renal failure in elderly patients. Nephrol Dial Transplant 2:316, 1987 5. Espinel CH. The FENa test. Use in differential diagnosis of acute renal failure. JAMA 236:579, 1976 6. Hall JW, Johnson WJ, Maher FT, et al. Immediate and long-term prognosis in acute renal failure. Ann Intern Med 73:515, 1970 7. Kjellstrand CM, Garnick C, Davin T. Recovery from acute renal failure. Clin Exp Dial Apheresis 5:14, 1981
REFERENCES Whittier JR: Asphyxiation, bulimia, and insulin levels m Huntington disease (chorea). JAMA 235:1423-1424, 1976 Hayden MR: Huntington's Chorea. Berlin, Springer-Verlag, 1981, p 145 Silverstone T: Psycopharmacology of hunger and food intake m humans. Pharmacol Ther 19:417-434,1983 Garattini S, Mennini T, Bendotti C, et al: NeurochemicaI mechanism of action of drugs which modify feeding via the serotoninergic system. Appetite 7(suppl):15-38, 1986
Chlorpromazine & Appetite To the Editor:-Anorexia and weight loss are common problems in the elderly, the demented, and the medically ill. Often this is either a manifestation of depression or a consequence of specific medical illness, and treatment is relatively straightforward. Frequently, however, no specific cause for anorexia can be found, and the physician must rely on empirical treatments to stimulate appetite. We recently successfully treated a patient with Huntington's disease and serious anorexia with chlorpromazine. Over a period of one year, a 55-year-old man with a 12year history of Huntington's disease refused food and drink with increasing frequency. This resulted in a weight loss of 24 pounds. Past medical history was significant for chronic
Editor's note: This patient was only 55 years of age, and Huntington's disease is rarely seen in the elderly. However, this letter may be of geriatric interest because of its suggestion that chlorpromazine might be tested in the idiopathic anorexia of the frail elderly.
Reducing Polypharmacy To The Editor:--I
read with interest the article entitled 'Reducing Polypharmacy in the Elderly-A Controlled Trial of Physician Feedback" by Doctors Kroenke and Pinholt.' There
104
LETTERS TO THE EDITOR
are several points that I would like to address concerning this study: 1.It was stated that when a "discrepancy [existed]between what had originally been prescribed, the questionnaire data and the pharmacist interview, the regimen determined at the time of the interview was considered the 'gold standard and served as the basis for formulating the investigators' recommendations", yet the authors do not elaborate on how the correct regimen was determined at the time of the interview, eg through review of the patient's chart, through contact with the patient's physician, or only through the information provided by the patient. The scenario presented in the latter case may not be the most reliable since the patient may have altered the dose he or she was taking without the physician's knowledge. I have seen this occur. 2. By only having a list of the patient's medications and not knowing very much else about the patient (such as the history and physical, laboratory data, response to drug therapy, adverse drug reaction history, etc) it is difficult to make intelligent decisions about what medications should be discontinued or substituted. In the Methods section of this paper the authors do not state that they reviewed patients' charts, yet in the Results section they imply that they may have in certain cases ("vague symptoms in the past that, upon further review [emphasis added] . . ."). There seems to be a gap in the exact decision making process that went into formulating recommendations. In addition, it does not appear that the pharmacist's expertise in drug therapy was utilized by the authors other than to perform drug histories. Further, it seems that recommendations on drug therapy were made by the investigating physicians independently of speaking with or seeing the patient. 3. Although the housestaff "were not formally made aware of the existence of a study" just being aware that a colleague is observing one's behavior may be enough to influence response. Furthermore, the investigators do not describe what their relationship is to the "firms." Were either one of the physicians the chief of medicine, the attending assigned to oversee the team, the chief resident, or someone who could be in a position of authority over the "firms?" If this is the case, such recommendations may be viewed more seriously or as measurements of a junior physician's ability to follow a senior physician's orders. 4. An elaborate explanation is provided on the complexity score, yet its significance is dubious. Perhaps a simplified way of viewing this complexity score is to say that a point was given for each time that a specific medication was used. The same idea is conveyed as the authors intended. Further, they state that an exception would be if the dosage intervals do not coincide, eg a patient who takes Drug A in the morning and Drug B in the evening would have a complexity score of 2. This is not an exception but follows the same logic that was used in deriving a complexity score of 7 when a patient takes Drug A 4 times a day, Drug B 2 times a day, and Drug C daily, even though the "patient may in fact merge dosage schedules." In order to have a true effect on simplifying a patient's dosage regimen, recommendations should have been based on advising patients to consolidate or better organize their actual medication-taking schedule. In order to do this, patient contact is necessary to ascertain how the patient is taking his/her medications and why they are doing this in such a way (ie, perhaps the patient was advised to space doses to avoid a drug interaction). The lack of clinical applicability of this scoring system is confirmed by the absence of a significant change in the complexity score after intervention despite a significant decrease in the number of medications and doses of medications, which have been both positively correlated with noncompliance.'
IAGS-IANUARY 1991-VOL. 39 NO. 1
5. The authors calculated cost, but the reference source that was used was from 1984. Newer drugs marketed since 1984 (eg ciprofloxacin, nizatidine) would not be included in this reference. 6. It is surprising that the problem of polypharmacy was not more prevalent (only 33%), but this may reflect the exclusion of over-the-counter medications and non-scheduled prescription drugs. What was even more surprising was that among the polypharmacy patients there were an approximately equal number of males and females. Increased medication use is generally considered a female The similar malelfemale ratio was probably attributable to the use of a military hospital. 7. The investigators state in the Results that there were 43 recommendations for 22 patients in the control group. By the very definition of a control group no communication should have taken place between the investigators and this group. Rather than make this assumption, it should have been clearly stated. 8. One recommendation involved switching patients on a diuretic (hydrochlorothiazide) and a potassium supplement to a potassium-sparing diuretic (particular drug not specified). It is important to keep in mind that not all potassium-sparing diuretics have a similar antihypertensive effect, eg amiloride's antihypertensive effect is similar to the thiazides, but triamterene's is not. Further, when the relative maximal potency or the maximum fraction of filtered sodium that is excreted following maximally effective doses of a drug is compared for thiazides and potassium-sparing diuretics (including spironolactone, triamterene, and amiloride), it is 5%-10% for the thiazides versus 300 mL, are presumably included in the normal CMG group, although this is not specified and these patients probably have detrusor instability contributing to their leakage. Finally, the authors do not specify how they decided a detrusor contraction was truly "involuntary" in this highly cognitively impaired population. Stress incontinence (SI) may also be underestimated since provocative stress testing was done at less than bladder capacity. Also, the absence of simultaneous detrusor pressure monitoring and
JAGS-IANUARY 1991-VOL. 39 NO. I
103
slightly greater in patients older than 70 years though the sinusitis and a closed head injury with bifrontal and biparietaI difference from younger ones did not reach statistical signif- contusions 5 years prior to the onset of anorexia; the anorexia icance (45% vs 41%). In the extensive group of patients did not correlate with exacerbations of sinusitis. He denied studied, we failed to show any relationship between ad- depression, slept well, and participated in recreational activivanced age and prognosis of ARF, in agreement with other ties. A trial of cyproheptadine, 4 mg tid, was ineffective as a ~ t h o r s . Prognosis ~-~ depended on the complications arising were aggressive treatment of sinusitis with antibiotics and an during the ARF episode. Four risk factors were found to be empirical trial of nortriptyline, 50 mg qhs. The latter was significantly related to mortality: need for dialysis, coma, discontinued, and chlorpromazine 25 mg bid was started. mechanical respiration, and hypotension. Deep neurological Within 48 hours the patient began to eat most or all of the coma was especially ominous; only 18% of those with this food that was presented to him. Choreiform movements were complication survived. Mortality was significantly higher in essentially unchanged. The patient has been successfully older patients requiring dialysis than in younger ones (79% maintained on this medication for 3 months and has regained vs 57%, p < 0.05). Mortality rates related to the other prog- 20 pounds. Anorexia is quite unusual in Huntington's disease; indeed, nostic factors were not different on the basis of age. Elderly patients who survived an ARF episode needed most patients are described as voracious eaters, possibly due more time for total recovery than younger people (11 days to increased caloric demand.',* It is possible that the patient's vs 7 days, p < 0.05, in pre-renal episodes and 22 days vs 19 head injury or the sinusitis might be related to the anorexia. days, NS, in acute tubular necrosis). Interestingly, all survi- This underscores the unfortunate reality that the etiology of vors recovered enough renal function to be removed from anorexia in such patients is frequently never determined. Most neuroleptics cause a degree of weight gain, chlordialysis. This was true in both age groups, in disagreement especially SO.^ The mechanism for this is not clear. with previous reports that age is a determinant for r e ~ o v e r y . ~ ,promazine ~ Age should not be used as a discriminant factor in therapeutic Chlorpromazine has a strong affinity for serotonergic recept o r ~ and , ~ serotonin blockade has been strongly associated decisions concerning ARF. with appetite stimulation in both animals and man! We are generally reluctant to treat debilitated and elderly J. PASCUAL, MD L. OROFINO, MD patients with chlorpromazine due to its high incidence of F. LIAKIo, MD postural hypotension. However, this may not be problematic R. MARC&,MD in bedridden or non-ambulatory patients. The risk of tardive L. ORTE,MD dyskinesia must of course be borne in mind in such patients J. ORTUKIO, MD as well. Aside from this, chlorpromazine is relatively well Nephrology Department tolerated and may also have the added benefit of treating Hospital Rambn y Cajal agitation or psychosis in certain patients. Thus, when used Madrid, Spain with caution, chlorpromazine may be a reasonable option for appetite stimulation in selected patients. ALANJ. WALDMAN, MD T. STEWART, MD Assistant Professor in Psychiatry University of Florida College of Medicine Gaines.de, FL
REFERENCES
JONATHAN
1. Roy AT, Johnson LE, Lee DBN, et al: Renal failure in older
people. UCLA Grand Rounds. J Am Geriatr SOC38:239,1990 2. Pascual J, Orofino L, Liaiio F, et al: Incidence and prognosis of acute renal failure in older patients. J Am Geriatr SOC38:25, 1990 3. Kumar R, Hill CM, McGeown MG. Acute renal failure in the elderly. Lancet 1:90, 1973 4. Lameire N, Matthys E, Vanholder R, et al. Causes and prognosis of acute renal failure in elderly patients. Nephrol Dial Transplant 2:316, 1987 5. Espinel CH. The FENa test. Use in differential diagnosis of acute renal failure. JAMA 236:579, 1976 6. Hall JW, Johnson WJ, Maher FT, et al. Immediate and long-term prognosis in acute renal failure. Ann Intern Med 73:515, 1970 7. Kjellstrand CM, Garnick C, Davin T. Recovery from acute renal failure. Clin Exp Dial Apheresis 5:14, 1981
REFERENCES Whittier JR: Asphyxiation, bulimia, and insulin levels m Huntington disease (chorea). JAMA 235:1423-1424, 1976 Hayden MR: Huntington's Chorea. Berlin, Springer-Verlag, 1981, p 145 Silverstone T: Psycopharmacology of hunger and food intake m humans. Pharmacol Ther 19:417-434,1983 Garattini S, Mennini T, Bendotti C, et al: NeurochemicaI mechanism of action of drugs which modify feeding via the serotoninergic system. Appetite 7(suppl):15-38, 1986
Chlorpromazine & Appetite To the Editor:-Anorexia and weight loss are common problems in the elderly, the demented, and the medically ill. Often this is either a manifestation of depression or a consequence of specific medical illness, and treatment is relatively straightforward. Frequently, however, no specific cause for anorexia can be found, and the physician must rely on empirical treatments to stimulate appetite. We recently successfully treated a patient with Huntington's disease and serious anorexia with chlorpromazine. Over a period of one year, a 55-year-old man with a 12year history of Huntington's disease refused food and drink with increasing frequency. This resulted in a weight loss of 24 pounds. Past medical history was significant for chronic
Editor's note: This patient was only 55 years of age, and Huntington's disease is rarely seen in the elderly. However, this letter may be of geriatric interest because of its suggestion that chlorpromazine might be tested in the idiopathic anorexia of the frail elderly.
Reducing Polypharmacy To The Editor:--I
read with interest the article entitled 'Reducing Polypharmacy in the Elderly-A Controlled Trial of Physician Feedback" by Doctors Kroenke and Pinholt.' There
104
LETTERS TO THE EDITOR
are several points that I would like to address concerning this study: 1.It was stated that when a "discrepancy [existed]between what had originally been prescribed, the questionnaire data and the pharmacist interview, the regimen determined at the time of the interview was considered the 'gold standard and served as the basis for formulating the investigators' recommendations", yet the authors do not elaborate on how the correct regimen was determined at the time of the interview, eg through review of the patient's chart, through contact with the patient's physician, or only through the information provided by the patient. The scenario presented in the latter case may not be the most reliable since the patient may have altered the dose he or she was taking without the physician's knowledge. I have seen this occur. 2. By only having a list of the patient's medications and not knowing very much else about the patient (such as the history and physical, laboratory data, response to drug therapy, adverse drug reaction history, etc) it is difficult to make intelligent decisions about what medications should be discontinued or substituted. In the Methods section of this paper the authors do not state that they reviewed patients' charts, yet in the Results section they imply that they may have in certain cases ("vague symptoms in the past that, upon further review [emphasis added] . . ."). There seems to be a gap in the exact decision making process that went into formulating recommendations. In addition, it does not appear that the pharmacist's expertise in drug therapy was utilized by the authors other than to perform drug histories. Further, it seems that recommendations on drug therapy were made by the investigating physicians independently of speaking with or seeing the patient. 3. Although the housestaff "were not formally made aware of the existence of a study" just being aware that a colleague is observing one's behavior may be enough to influence response. Furthermore, the investigators do not describe what their relationship is to the "firms." Were either one of the physicians the chief of medicine, the attending assigned to oversee the team, the chief resident, or someone who could be in a position of authority over the "firms?" If this is the case, such recommendations may be viewed more seriously or as measurements of a junior physician's ability to follow a senior physician's orders. 4. An elaborate explanation is provided on the complexity score, yet its significance is dubious. Perhaps a simplified way of viewing this complexity score is to say that a point was given for each time that a specific medication was used. The same idea is conveyed as the authors intended. Further, they state that an exception would be if the dosage intervals do not coincide, eg a patient who takes Drug A in the morning and Drug B in the evening would have a complexity score of 2. This is not an exception but follows the same logic that was used in deriving a complexity score of 7 when a patient takes Drug A 4 times a day, Drug B 2 times a day, and Drug C daily, even though the "patient may in fact merge dosage schedules." In order to have a true effect on simplifying a patient's dosage regimen, recommendations should have been based on advising patients to consolidate or better organize their actual medication-taking schedule. In order to do this, patient contact is necessary to ascertain how the patient is taking his/her medications and why they are doing this in such a way (ie, perhaps the patient was advised to space doses to avoid a drug interaction). The lack of clinical applicability of this scoring system is confirmed by the absence of a significant change in the complexity score after intervention despite a significant decrease in the number of medications and doses of medications, which have been both positively correlated with noncompliance.'
IAGS-IANUARY 1991-VOL. 39 NO. 1
5. The authors calculated cost, but the reference source that was used was from 1984. Newer drugs marketed since 1984 (eg ciprofloxacin, nizatidine) would not be included in this reference. 6. It is surprising that the problem of polypharmacy was not more prevalent (only 33%), but this may reflect the exclusion of over-the-counter medications and non-scheduled prescription drugs. What was even more surprising was that among the polypharmacy patients there were an approximately equal number of males and females. Increased medication use is generally considered a female The similar malelfemale ratio was probably attributable to the use of a military hospital. 7. The investigators state in the Results that there were 43 recommendations for 22 patients in the control group. By the very definition of a control group no communication should have taken place between the investigators and this group. Rather than make this assumption, it should have been clearly stated. 8. One recommendation involved switching patients on a diuretic (hydrochlorothiazide) and a potassium supplement to a potassium-sparing diuretic (particular drug not specified). It is important to keep in mind that not all potassium-sparing diuretics have a similar antihypertensive effect, eg amiloride's antihypertensive effect is similar to the thiazides, but triamterene's is not. Further, when the relative maximal potency or the maximum fraction of filtered sodium that is excreted following maximally effective doses of a drug is compared for thiazides and potassium-sparing diuretics (including spironolactone, triamterene, and amiloride), it is 5%-10% for the thiazides versus 300 mL, are presumably included in the normal CMG group, although this is not specified and these patients probably have detrusor instability contributing to their leakage. Finally, the authors do not specify how they decided a detrusor contraction was truly "involuntary" in this highly cognitively impaired population. Stress incontinence (SI) may also be underestimated since provocative stress testing was done at less than bladder capacity. Also, the absence of simultaneous detrusor pressure monitoring and
