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Delirium is common in hospitalized older adults. The condition is frequently not recognized, or managed appropriately, and has a poor prognosis. This review finds that a proactive multicomponent interdisciplinary non-farmacological approach can reduce incidence. Delirium is managed by identification of the condition, accurate diagnosis and treatment of the causes, and all other correctable contributing factors, using nonpharmacologic approaches. In some cases, and if required for patient safety, low doses of high-potency antipsychotic agents can be used, in lowest possible dose and for the shortest possible time.

Background: Use of drugs with anticholinergic properties (DAP) has a negative impact on older people., Objective: Our aim was to examine the association between DAP at hospital admission and mortality in older patients., Patients and Methods: We performed a nationwide population-based cohort study including patients aged ≥ 65 years admitted to Danish geriatric medicine departments during 2005-2014. National health registers were used to link with individual-level data. Patients were followed to emigration, death, or study termination (31 December 2015). DAP was defined as medications included in the anticholinergic cognitive burden (ACB) scale, which assigns each DAP a score between 1 and 3. The individual ACB score was calculated and the number of DAP counted. We used Cox proportional-hazard regressions to estimate the crude and adjusted hazard ratios adjusting for age, activities of daily living, marital status, index admission period, BMI, and prior hospitalizations (model 1), and additionally Charlson Comorbidity Index (model 2)., Results: We included 74,589 patients aged (median [IQR]) 83 (77-88) years. Use of one or more DAP (62.5%) was associated with increased mortality compared with those with no use (p < 0.001). In the fully adjusted model 2, compared with no use, higher mortality risks (HR [95% CI]) were seen with ACB score of 2 and number of DAP ≥ 5 for 30-day (1.46 [1.32-1.61] and 1.46 [1.09-1.95]), 1-year (1.34 [1.28-1.41] and 1.48 [1.29-1.70]), and overall mortality (1.27 [1.23-1.31] and 1.44 [1.31-1.59]), respectively., Conclusions: Use of DAP at hospital admission is associated with short- and long-term mortality in geriatric patients. Deprescribing studies are warranted to study whether the impact on mortality can be attenuated., (© 2021. The Author(s).)

Background Studies have shown poor post-discharge implementation by the general practitioner of changes made to patients' medication during admission. Objective To assess the feasibility of conducting telephone conferences delivering information about changes in older patients' medications from hospital to general practitioners. Setting Two departments of geriatric medicine in a Danish routine healthcare setting. Method Older polypharmacy patients (≥ 65 years and ≥ 5 prescriptions) consecutively admitted were eligible for inclusion. Telephone conferences based on a review of these patient's medication therapy during hospital stay were arranged between a pharmacist and a geriatrician from the hospital, and a general practitioner. Interviews were conducted with pharmacists, geriatricians, and general practitioners about their perspectives on the feasibility of telephone conferences. Interviews were analyzed using systematic text condensation. Main outcome measure The proportion of telephone conferences conducted and perspectives on the feasibility of the study. Results A total of 113 patients were included and 82 patients (75%) were eligible for telephone conferences. A total of 40 (49%) telephone conferences were conducted. The main reasons for conferences not being conducted were general practitioners not wanting to participate or not returning the calls from the pharmacists. Three themes emerged from the qualitative analysis: considerations on planning and running the project, Barriers, facilitators, and implications of the telephone conference, and Actual and desirable cross-sectorial communication. Conclusion Telephone conferences were only possible for half of the patients. The participating general practitioners, pharmacists and geriatricians expressed varied benefit and agreed that telephone conferences were mainly relevant for complex patients., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Older patients admitted to the emergency departments represent a heterogeneous group, some are frail with reduced reserve capacity and without ability to compensate to acute illness. They often present with nonspecific complaints and atypical presentation and are at-risk of complications and adverse events. These patients need a fast comprehensive interdisciplinary and multicomponent assessment and intervention to reduce the risk of further functional decline and to optimize their overall health status, independency and quality of life. This is the purpose of acute geriatrics.

Treatment guidelines are primarily based on randomized clinical trials (RCTs). RCTs tend to some extent to exclude older adults despite the fact that physicians need guidance when treating this patient group. By summarizing existing literature, we aimed to (a) quantify the proportion of RCTs and other clinical studies (CTs) that did not adequately include older adults; (b) identify the main barriers for this non-inclusion; and (c) identify suggested solution for inclusion of older adults in RCTs and other CTs. In this umbrella review, Embase and PubMed were searched for relevant papers, and 2701 papers were identified. The subsequent screening resulted in 22 papers. The Critical Appraisal Skills Program was used as quality assessment tool to evaluate these 22 papers. We found that: (a) The most frequent outcome designating missing inclusion of older adults was the use of age limit as exclusion criterion in studies-the proportion of this was 10%-60%; (b) barriers for inclusion were mainly exclusion criteria, logistic challenges and financial constraints; and (c) more extensive inclusion would require more explicit inclusion criteria, merely application of exclusion criteria when absolutely needed, change of researchers' attitude, further inclusion of supporting relatives to overcome the logistical challenges and more financial funding., (© 2020 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).)

Background: The incidence of most cancers increases with age from early adulthood into old age but tends to level off or decrease at the highest ages. This decline may be caused by age-related mechanisms or due to lower diagnostic activity, leaving some cancers undiagnosed at the oldest ages., Methods: For breast, colon, lung, and all sites except non-melanoma skin cancer, age-specific incidence rates of verified as well as suspected cancer were estimated up to ages 95+ years for a random sample of the Danish population, 1994-2011, based on nationwide health registers (40,008 verified and 9110 suspected cancers). Moreover, for cancers diagnosed in Denmark, 1978-2012 (613,384 cancers), age-specific percentages of tumors with microscopic verification (histological/cytological/hematological examination) were calculated., Results: The age-specific cancer incidence rates reached a peak between ages 65-89 years after which rates declined. The corresponding incidence pattern of suspected but not verified cancer was similar, with a trend of a slight absolute and relative decrease with age compared to verified cancer incidence. The proportion of cancers with microscopic verification decreased linearly from approximately 95% at ages 0-69 years all years to 70% (1978-1982) and to 80% (2010-2012) at ages 90+ years., Conclusions: The lower diagnostic verification of cancer at the highest ages suggests a lower diagnostic activity among the oldest-old. However, the proportion of suspected but not verified cancers did not increase with age, possibly partially due to lack of registration. The declining cancer incidence at oldest ages is probably partly due to lower diagnostic activity., (Copyright © 2019. Published by Elsevier Ltd.)

Objectives: This study aims to describe the association between use of municipality healthcare services before an emergency department (ED) contact and mortality, hospital reattendance and institutionalisation., Design: Population-based prospective cohort study., Setting: ED of a large university hospital., Participants: All medical patients ≥65 years of age from a single municipality with a first attendance to the ED during a 1-year period (November 2013 to November 2014)., Primary and Secondary Outcome Measures: Patients were categorised as independent of home care, dependent of home care or in residential care depending on municipality healthcare before ED contact. Patients were followed 360 days after discharge. Outcomes were postdischarge mortality, hospital reattendance and institutionalisation., Results: A total of 3775 patients were included (55% women), aged (median (IQR) 78 years (71-85)). At baseline, 48.9% were independent, 34.9% received home care and 16.2% were in residential care. Receiving home care or being in residential care was a strong predictor of mortality, hospital reattendance and institutionalisation. Among patients who were independent, 64.3% continued being independent up to 360 days after discharge. Even among patients ≥85 years, 35.4% lived independently in their own house 1 year after ED contact., Conclusion: Prehospital information on municipality healthcare is closely related to patient outcome in older ED patients. It might have the potential to be used in risk stratification and planning of needs of older acute medical patients attending the ED., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The objective was to describe the prevalence of geriatric conditions among older medical patients in the emergency department (ED) and the association with admission, mortality, reattendance and loss of independency., Design: Population-based prospective cohort study., Setting: ED of a large university hospital., Participants: All medical patients ≥65 years of age from a single municipality with a first attendance to the ED during a 1-year period (November 2013 to November 2014)., Primary and Secondary Outcome Measures: Based on information from healthcare registers, we defined geriatric conditions as disability, recently increased disability, polypharmacy and comorbidity. Outcomes were admission, length of admission, 30 days postdischarge mortality, 30 days hospital reattendance and home care dependency 0-360 days following ED contact., Results: Totally, 3775 patients (55% women) were included, age 78 (71-85) years (median (IQR)). No patients were lost to follow-up. The prevalence of 0-4 geriatric conditions was 14.9%, 27.3%, 25.2%, 22.3% and 10.3%, respectively. The number of conditions was significantly associated with hospital admission, length of admission, 30 days postdischarge mortality and 30 days hospital reattendance. Among patients with no geriatric conditions, 70% lived independent all 360 days after discharge, whereas all patients with ≥3 conditions had some dependency or were dead within 360 days following discharge., Conclusion: Among older medical patients in the ED, 50% had two or more geriatric conditions which were associated with poor health outcomes. This highlights the need for studies of the effect of geriatric awareness and competences in the ED., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Follow-up in general practice on medication initiated during hospitalisation is often perceived to be inadequate, which leads to unintended drug interaction and over- or underdosage of medication. Little is known about General Practitioners (GPs') views on medication changes during the transition from hospital to primary care. We conducted a qualitative interview study to understand GPs' views on the medication changes made for their patients by hospital physicians in a geriatric ward and the GPs' actions after discharge., Methods: Qualitative semi-structured interviews comprising ten GPs from general practices in the Region of Southern Denmark, using a phenomenological approach. The GPs were selected strategically based on the principle of maximum variation. The analysis process was a cross-sectional analysis based on a phenomenological analysis., Results: The GPs identified many reasons for the lack of medication continuation, including miscommunication between hospital doctors and GPs and delayed discharge letters. Several factors were involved, including patients not taking responsibility for their medication, no structure for follow-up visits to their GPs and for the renewal of their prescriptions., Conclusion: The main reason for the poor continuity of medication changes for geriatric patients at sector transition was neither the GPs' deliberate actions of removing the patients' medications, nor the patients' lack of compliance or of willingness to take the medication. It is largely due to procedural errors in the follow-up on the patient after discharge, due to the lack of a structured process and due to miscommunication between the primary sector and the hospital.

This article focuses on patients with limited life expectancy who no longer benefit from preventive medication but not yet qualify for palliative care - a time frame often referred to as End-of-Life (EOL). The purpose of this article is to identify and assess international guidelines for prescribing in EOL. No relevant clinical trials were available, but we found advice mainly based on logic assumptions and thoughts. Optimal prescribing for EOL patients remains mostly unexplored. Our study revealed two pivotal questions: How do we identify EOL patients, and what specific drugs should be removed?

Elderly patients are often prescribed several drugs, which might increase the risk of drug-related harms and the risk of not using the drugs as prescribed, both of which can result in increased costs. The literature supports the conclusions in a newly published Cocranereview on four randomized controlled trials (RCT) showing that it is uncertain whether medication reviews reduce mortality or hospital readmissions, but medication reviews seem to reduce emergency department contacts. However, further RCT are needed before implementing medication reviews.

Background: Comprehensive geriatric assessment of hospitalised patients implies optimising patients' medical treatment, and good coordination between hospital and general practice is essential for the quality of the drug treatment. Only a few studies have investigated the continuation of patients' medication from primary care to hospital and back again to primary care., Objectives: To describe changes of drug therapy during hospital stay in a geriatric ward and the following acceptance of these changes in primary cares after discharge., Methods: An observational register study following 1,550 geriatric patients' pharmacological treatment longitudinally across hospital stay, by linkage of a primary care prescription database and hospital medical records. The medication regimens for the individual patients were compared at three cross sections: primary care before hospitalisation, during hospital stay and primary care after hospitalisation, analysed according to drug therapy, co-morbidity, functionality and outpatient follow-up., Results: Patients were using an average of 8.2 drugs before hospital admission, of which an average of 0.9 drugs per patient was discontinued or switched during hospitalisation. An average of 1.7 new drugs per patient was initiated by the hospital physicians. After discharge, 63.9 % of the changes initiated by hospital physicians were continued in primary care. Of new drugs initiated in hospital 42.7 % were accepted in primary care., Conclusions: A relatively small proportion of drugs was switched or discontinued and the average number of drugs increased during hospital stay. Of these changes, two thirds were accepted in primary care after discharge and less than half of newly initiated drugs were continued in primary.

Objective: Incomplete medication histories obtained on hospital admission are responsible for more than 25% of prescribing errors. This study aimed to evaluate whether pharmacy technicians can assist hospital physicians' in obtaining medication histories by performing medication reconciliation and prescribing reviews. A secondary aim was to evaluate whether the interventions made by pharmacy technicians could reduce the time spent by the nurses on administration of medications to the patients., Methods: This observational study was conducted over a 7 week period in the geriatric ward at Odense University Hospital, Denmark. Two pharmacy technicians conducted medication reconciliation and prescribing reviews at the time of patients' admission to the ward. The reviews were conducted according to standard operating procedures developed by a clinical pharmacist and approved by the Head of the Geriatric Department., Findings: In total, 629 discrepancies were detected during the conducted medication reconciliations, in average 3 for each patient. About 45% of the prescribing discrepancies were accepted and corrected by the physicians. "Medication omission" was the most frequently detected discrepancy (46% of total). During the prescribing reviews, a total of 860 prescription errors were detected, approximately one per medication review. Almost all of the detected prescription errors were later accepted and/or corrected by the physicians. "Dosage and time interval errors" were the most frequently detected error (48% of total). The time used by nurses for administration of medicines was reduced in the study period., Conclusion: This study suggests that pharmacy technicians can contribute to a substantial reduction in medication discrepancies in acutely admitted patients by performing medication reconciliation and focused medication reviews. Further randomized, controlled studies including a larger number of patients are required to elucidate whether these observations are of significance and of importance for securing patient safety.

To improve medication in the elderly several screening tools have been developed. The most used tool is the Beers 2003 criteria; however, the newer STOPP/START criteria have proven more effective and easier to use. Based on the literature we aim to compare these tools according to a list of desired properties and to suggest the best template for a Danish tool, though it is still to be determined, whether the identification and correction of potentially inappropriate medication leads to a better outcome in terms of decreased morbidity and mortality and improved health economics.

Evaluating post-graduate trainees under direct observation is troublesome, and there are concerns about rater-variability. The aim of this study was to explore if video recordings could be used for evaluation. The performances of five trainees were video recorded. The videos were assessed by six supervisors watching either the complete recording or approximately 20 min. Video recording was well tolerated by the patients and the supervisors, but not the trainees. Watching part of the videos was sufficient for assessment. Video recording seems to provide a feasible method of assessing postgraduate trainees.

Background: Auscultatory measurement using a sphygmomanometer has been the predominant method for clinical estimation of blood pressure, but it is now rapidly being replaced by oscillometric measurement., Objective: To compare blood pressure by auscultatory and oscillometric measurements in patients ≥ 80 years., Method: 100 patients had blood pressure measured by auscultation with a sphygmomanometer and by an electronic device using the oscillometric method. For each patient the mean of two blood pressures with each method measured within 15 min were compared., Results: The mean age of participants was 85.8 years; 55.8% were women. The correlation coefficient for systolic blood pressure was 0.88 and for diastolic 0.79. Differences between auscultatory and oscillometric values were less than 10 mmHg in 70.6% of systolic blood pressures and in 83.2% for diastolic. Arrhythmia and hypertension did not influence the results, and there was no correlation between the magnitude of the differences and the level of blood pressure., Conclusion: Agreement between oscillometric and auscultatory measurements of blood pressure in octogenarians was found to be less than required by validation protocols. However, semi-automatic equipment, which is observer-independent, may be used even in the very elderly, particularly if multiple readings are performed.

How should a theoretical postgraduate course be organized to obtain maximum effect? We report an example of a two-day course planned and implemented according to educational approaches previously shown to be effective. The theme of the course is "The old patient", and the course is compulsory for residents in internal medicine. This case study showed that the methods used were feasible, and the participants gained knowledge. A multiple-choice test before and after the course showed 44% (before) and 64% (after) correct answers, p < 0.001.

Background: The new antidepressants are generally effective and safe for older people, but may have serious side-effects. The use has been rapidly increasing, but focus on upper age groups has been limited. The pattern of antidepressant use as death approaches has never been analysed., Objective: To analyse the use of antidepressants among individuals aged 65 years and above with respect to time trends, age and proximity to death., Design: Population-based prescription study., Setting: The County of Funen, Denmark, 1992-2004 (approximately 470,000 inhabitants)., Results: The 1-year prevalence of antidepressants increases steadily over time in all age groups. Among the 65+ year-olds it also increases with age and differs substantially between the youngest and the oldest. Very high prevalences are observed: 26.8% among females 85-89 years old and 17.5% among males 85 years and above in 2004. In all age groups the use of antidepressants increases substantially with proximity to death in the last 3 years of life. In the last phase of life the use is independent of whether the patient dies at age 65 or 90 about 33% of females and 25% of males receive antidepressants in the last 6 months., Conclusions: The use of antidepressants among 65+ year-olds increases with age and proximity to death to very high levels. Future studies may clarify the problems and diagnoses giving rise to the use of antidepressants for such a large proportion of older people, and especially the problems giving rise to treatment as death approaches.

Background: Most antidepressant treatment is initiated and continued in general practice but, despite current guidelines, treatment duration is often short among patients with depression. Discontinuation may, however, be caused by a complexity of factors, but so far research has focused on drug effects, adverse effects and drug regimens., Objective: Our aim was to analyse whether early discontinuation of first-time antidepressant treatment in general practice may be predicted by (i) social position and psychiatric history of the patient; and (ii) demography, practice activity and the general prescribing behaviour of the GP., Methods: Early discontinuation, i.e. that patients do not purchase antidepressants in the 6 months following first prescription, was analysed using established databases. Among patients presenting in 174 general practices in Funen County, Denmark, 4860 adult first-time users of antidepressants were identified (regardless of diagnosis). The inclusion period was January 1998-June 1999., Results: One in three patients did not purchase antidepressants in the 6 months following first prescription, but rates were higher among those prescribed tricyclic compared with new generation antidepressants. Patients' age and sex did not have an influence, but early discontinuation was more frequent among patients of low socio-economic status and patients prescribed in practices characterized by high prescribing rates. No association with psychiatric history was observed., Conclusion: Early discontinuation is frequent in general practice, and patients of low social status are at greater risk. Adherence-promoting strategies should pay attention to the high prescribing doctors. Further studies may answer the question of whether the association between doctors' prescribing behaviour and early discontinuation is a feature specific to antidepressants or a more general phenomenon.

Objective: To analyse whether first-time use of antidepressants (incidence) and selection of TCAs (tricyclic antidepressants) versus new-generation drugs are associated with socio-economic status and psychiatric history., Method: We conducted a population-based cohort study using registry data covering Funen County, Denmark. A total of 305,953 adult residents without antidepressant prescriptions 5 years prior to the study period (1998) were included., Results: The 1-year incidence rate of antidepressant prescription (1.7%) increased with age. It was higher in people who were female, less educated, unemployed, those receiving old-age or disability pension, low-income groups, and singles. The proportion prescribed new-generation antidepressants (82%) showed no difference according to socio-economic variables (education, annual income and socio-economic group), but was higher among the young and single. Admission to psychiatric hospital within 4 years prior to the study period was associated with high-incidence rate of antidepressant prescription and overall a preference for the new-generation antidepressants., Conclusion: Socio-economic status did not seem to influence the selection of TCAs versus new-generation antidepressants. Compatible with the general epidemiology of depression, low socio-economic status was associated with a high number of first-time users of antidepressants in the population, and the incidence rate increased with age.

Objective: The use of antidepressants (ADs) has escalated and prompted considerable debate. Many depressed patients go unrecognised or under-treated and the area of indication of the new ADs is widening. The aim of this study was to analyse (i). the variation in general practitioners' prescribing of ADs by comparing with prescribing of other drug groups and (ii). whether the general prescribing behaviour, practice activity and demography are associated with the AD prescribing., Methods: Analysis of AD prescribing patterns among 174 general practices (93.5%) in the County of Funen, Denmark. Age- and sex-standardised 1-year incidences and prevalences of AD prescribing for patients listed were calculated using individual prescription data from Odense University Pharmacoepidemiologic Database. Data about health services and practice demography were obtained from the Health Insurance Register. The variation in AD 1-year prevalence was compared with other drug groups by a variation index (90%/10% percentile). Univariate linear regression analysis was used to examine associations between practice characteristics and prescribing., Results: The 1-year prevalence of AD prescribing varied sixfold, no more than the prevalence of five other drug groups. Practices with high yearly: general prescribing prevalence, mean number of drugs per medicated patient, number of surgery consultations/100 patients and counsellings/100 surgery consultations showed the highest yearly prevalence of AD prescribing. Single-handed practices had higher AD prescribing rates than partnerships. The relative use of selective serotonin re-uptake inhibitors and other new ADs showed only little variation (10% and 90% percentiles as close as 66-86%), but practices with high 1-year prevalence and incidence most often chose the new ADs., Conclusion: Analysis of inter-practice variation showed no extraordinary quality problems with regard to AD prescribing, but does not exclude that there might be problems. The general prescribing pattern of the general practitioners seems essential to their attitude to AD prescribing. The relationship between counselling and prescribing was a feature specific to ADs and deserves further investigation. Quality indicators are needed to understand differences in AD prescribing, and studies based on prescription data have to be supplemented with individual clinical data.

Introduction: The aim of the present study was to describe the occurrence of antidepressant treatment in geriatric departments in Denmark and assess the notes of the patient records in connection with prescription., Material and Methods: Patient records for consecutively referred patients in seven geriatric departments were examined and basic information was noted. For users of antidepressants further information about the treatment was noted., Results: A total of 1211 patients records were examined and out of these 338 patients were in treatment with antidepressants (29.7%). The users of antidepressants used more drugs on their discharge from the hospital. For 61.8% (209/338) of the users the treatment had started before the admission and in more than three-fourths the treatment remained unchanged at their discharge, in 9% the treatment was discontinued. 38.2% (129/338) started their treatment during the admission. Depression was stated as being the main reason in 54% of those who continued an ongoing treatment, and in 78% of those who started their treatment during admission. In 98.4%, the beginning of treatment with antidepressants was based upon the file notes. In 34.8% of the records of ongoing treatment no file notes were given., Discussion: Treatment with antidepressants is common in geriatric departments and most often it is a question of continuation of a treatment that had started before the admission. The study shows that there is a need for an optimization of the file notes.

Objective: Hyponatraemia is one of the major problems in geriatric inpatients. However, in nonhospitalised elderly, the preponderance of hyponatraemia and the importance of the effect of drug intake on serum sodium concentrations are little known. This study investigated the prevalence of hyponatraemia in very old nonhospitalised people, controlling for factors that may induce hyponatraemia (especially drug use)., Methods: Data on serum sodium concentration, health and drug use were retrieved for 185 persons aged 92 to 93 years (the 1905 cohort) and 147 persons aged 100 years (the centenarian cohort) participating in two major population-based studies of elderly people in Denmark. Data were analysed by comparing median serum sodium concentrations between users and nonusers of various drugs after controlling for the influence of age, sex, cancer, heart failure, hypothyroidism, renal failure and smoking. Furthermore, the preponderance of drug use in the patients with clinically relevant hyponatraemia was compared with that in persons with normal serum sodium concentrations., Results: Median serum sodium concentration was 140 mmol/L for the centenarians and 141 mmol/L for the 1905 cohort. In total, 19 persons had hyponatraemia (serum sodium concentration < or =134 mmol/L). There was no association between median serum sodium concentration and any of the above-mentioned diseases, or sex or smoking. Of the drugs generally known to cause hyponatraemia, only omeprazole and oral antidiabetic agents were associated with significantly lower median serum sodium concentrations (difference 3 mmol/L). Use of thiazide diuretics was significantly more common than expected in persons with hyponatraemia compared with persons with a normal serum sodium concentration (7 of 19 vs 46 of 270 individuals). Furthermore, the results suggested that digoxin and lactulose might be associated with a lowered median serum sodium concentration., Conclusion: This study demonstrates that severe hyponatraemia was rarely seen in a population-based sample of very old persons and that drugs have only a limited influence on serum sodium concentration. The only drug class associated with clinically relevant hyponatraemia was thiazide diuretics, which were used by significantly more persons with hyponatraemia. Furthermore, this study suggests that digoxin and lactulose use is associated with lower serum sodium concentrations in the elderly.

Objective: The aim of this study was, on the basis of data from health-care registers, to describe the adequacy of psychopharmacological treatment in suicides., Method: Data on consecutive suicides in a Danish County (Funen) in the period of 1 April 1991-31 December 1995 were identified in the Danish Psychiatric Central Register, the National Patient Register, the National Health Insurance and Odense University Pharmacoepidemiological Database., Results: Twenty-five per cent of the suicides previously hospitalized due to affective disorders and 3% of the suicides without psychiatric hospitalizations at all, received an apparently adequate treatment with antidepressants the month before suicide., Conclusion: The most striking finding was the insufficiency of treatment with antidepressants in the group of suicides without psychiatric hospitalization, in particular in light of the fact that depression is assumed to be present in at least 50% of all suicides.

Aim: The aim of the present study was to analyse the utilisation of antidepressants (ADs) and to compare the utilisation of the various ADs with special reference to duration of treatment courses., Method: From the Odense Pharmacoepidemiologic Database (OPED), all users of and prescriptions for ADs in the County of Funen, Denmark (about 470,000 inhabitants), were identified for each year from 1992 to 1997 (6 years). Duration of treatment courses was calculated for the first incident period of continuous use of one AD and was compared for the various ADs using Kaplan-Meiers survival statistics with log rank tests. Continuous use was defined as use of a minimum of one tablet per day. Furthermore, the proportion of users presenting only one prescription was determined for each AD., Results: In total, 37,598 patients presented 392,524 prescriptions during 1992-1997. The 1-year prevalence rose from 2.1% to 4.1% in 1997 and the incidence was 1.3% in 1997. The 1-year prevalence increased with age up to 16.5% in 1997 for patients aged 90 years or older. Citalopram was the most-used AD, but there were still a considerable number of patients commencing treatment with TCAs in 1997. Median duration of treatment courses was 196 days for TCAs versus 120 days for SSRIs (P < 0.0001). Duration of treatment courses increased with age. The proportion of users presenting only one prescription was 22% for the SSRIs versus 33% for tricyclic antidepressants (TCAs)., Conclusion: This study showed that the use of ADs continues to increase because of the increase in the use of the new ADs. There was, however, still a considerable number of patients who started on TCA treatment in 1997. For repeated prescriptions, TCAs were used for longer times than SSRIs. In the very old, there was an apparently inappropriate high use of ADs.

Background: Biochemical liver function tests are widely used in the clinic and are some of the most frequently used tests in screening for diseases in older age groups. The aim of the present study was to estimate the relative importance of genetic and environmental factors to variations in these tests among the elderly., Methods: We conducted a survey among Danish twins, 73-102 years of age, identified in the population-based Danish Twin Registry. Among the 2749 individuals in the study population, an interview was conducted with 79%. From these, a blood sample was collected from 290 same-sex twin pairs, total of 580 subjects, within a 6-month period and analyzed for alanine aminotransferase (ALT), lactate dehydrogenase (LDH), gamma-glutamyltransferase (GGT), bilirubin, and albumin. The interview included questions about alcohol consumption and body mass index (BMI; self-calculated height and weight). Heritability (proportion of the population variance attributable to genetic variation) was estimated using structural-equation analyses before and after correction for alcohol consumption and BMI., Results: Structural-equation analyses revealed a substantial heritability (35-61%) for the four biochemical liver function tests: ALT, GGT, LDH, and bilirubin. The remaining variation could be attributed to individuals' nonfamilial environments. Adjustment for alcohol consumption and BMI had no influence on the heritability for ALT, GGT, LDH, and bilirubin. For albumin, two models fit equally well before adjustment for alcohol and BMI: a model including additive genetic and nonshared environmental factors (AE), and a model including shared and nonshared environmental factors (CE). After adjustment, the model including shared and nonshared environment was clearly the best fitting model., Conclusions: For both males and females, the effect of genetic factors on the biochemical liver function tests ALT, GGT, LDH, and bilirubin is substantial and accounts for one-third to two-thirds of the variation among individuals 73-102 years of age. The heritability is equal for males and females and does not change notably after controlling for alcohol consumption and BMI. For albumin, no major impact of genetic factors was found independent of BMI and alcohol consumption. An understanding of the genetic mechanisms underlying biochemical liver function tests among the very old may be of value in the interpretation of these tests in this age group.

Objective: The purpose of this study was to describe suicides' contacts with various parts of the health-care system., Method: Data on 472 people who committed suicide in a Danish County (Funen) in the period of April 1 1991 to December 31 1995 were searched in the Danish Psychiatric Central Register, the National Patient Register, the National Health Insurance and Odense Pharmacoepidemiologic Database., Results: In total, 97.5% of the suicides were recaptured in at least one of these registers. Forty-two per cent had been hospitalized in psychiatric departments. Within the last month before death, 66% consulted a general practitioner, 13% and 7%, respectively, were discharged from a psychiatric hospital and general hospital., Conclusion: The registers used provided a comprehensive registry-based description of suicides' contacts with the health-care system. The most prominent features were the high prevalence of psychiatric morbidity and the high rate of contacts with GPs close to suicide.

The aim was to investigate estimators of polypharmacy (PP) from a population based prescription database. Data were retrieved from Odense Pharmacoepidemiological Database and contained a 10% random sample (n = 26,977) of drug users in 1994. PP was defined as simultaneous treatment with different drugs, and the duration of treatment was calculated from the date of purchase and the number of defined daily doses prescribed. This estimator was compared with an estimator based on the number of drugs purchased during a three month period. On an average day 8.7% were exposed to minor PP (two to four drugs) and 1.2% to major PP (five or more drugs). Purchase of five or more drugs during a three month period predicted episodes of major PP with a positive predictive value of 80%. Epidemiological measures of multiple drug use can be estimated from a prescription database. Conceptually, an estimator based on the number of simultaneously used drugs is preferable, but the number of drugs purchased during a three month period may be a useful alternative estimator.

Objective: To analyze the use of all subsidized prescription drugs with special attention to the elderly (> or = 70 years of age), including their use of drug combination generally accepted as carrying a risk of severe interactions., Design: Descriptive prevalence study., Setting: Odense Pharmacoepidemiological Database, Denmark. The fourth quarter of 1994., Subjects: All inhabitants in the county of Funen, Denmark., Main Outcome Measures: Prevalence of drug use for persons < 70 and > or = 70 years of age including number of drugs used and of drug combinations. Occurrence of 45 drug combinations generally accepted as carrying a risk of severe interactions., Results: Among persons less than 70 years, 67.9% used none, 16.5% used one drug and 15.6% used two or more prescription drugs. The corresponding prevalences for the elderly were 35.7%, 15.9% and 48.4%. The 26,337 elderly patients with at least two drugs used 21,293 different combinations. Of the elderly patients who had purchased > or = two drugs, 4.4% had combinations of drugs carrying a risk of severe interactions., Conclusions: Most elderly use drugs and usually several drugs concomitantly. The elderly form a heterogeneous group of drug users. Drug combinations carrying a risk of severe interactions are relatively frequent.

In order to elucidate potential problems concerning the use of antidepressants in general practice, 98 randomly selected antidepressant users from 12 general practices were interviewed. The primary indication for antidepressant treatment was depression (72 patients), partly regular depression (therapeutic/prophylactic treatment) (n = 39), partly depressive tendencies (n = 32) (one patient no information). Median treatment duration was three years; 25% had been in treatment for more than 10 years. The general practitioners judged the treatment problematic/unacceptable in 23 cases, largely because of uncertain indication or because other or no treatment was considered better for the patient. Side effects were modest. The patients often had a relatively high depression score and poor status according to the WONCA-scale. The use of low doses, long duration of treatment, and uncertainty about the relevance of the treatment are important features in the use of antidepressants by general practitioners. The use of antidepressants in general practice differs from the scientifically-based recommendations.

Objective: To evaluate the relationship between drug use and self-rated health in the elderly., Materials: An interview survey among all individuals aged 75 years or over in the Danish Twin Register took place. The survey comprised of 2171 persons who responded to questions on self-rated health and drug use., Results: The mean number of all drugs used increased from 1.3 in persons with "very good" health to 4.6 in persons with "very poor" self-rated health. For prescription drugs, the corresponding figures were 0.5 vs 1.8, respectively. Among persons using no drugs, 45.8% reported "very good" health, compared with only 6.4% of the persons using five or more drugs. Only 4% of persons using no drugs reported "poor" or "very poor" health. Further, the probability of having a poorer self-rated health increased with the number of drugs used, even though the tendencies were less clear for users of three or more drugs, particularly in the oldest persons. Users of opioids clearly had a poorer self-rated health compared with users of other drug groups., Conclusion: This study shows a relationship between self-rated health and drug use among elderly. Danish twins, who have previously been shown to have health characteristics similar to those of the general population. This suggests that drug use is a good proxy for self-rated health and, in particular that limited drug use is a proxy for good health. This observation may point towards additional research potentials for automated drug databases.

Objective: To study whether the newer antidepressants have changed the patterns of antidepressant use, and whether the claimed better adverse effect profile of the lower antidepressants is reflected in their use as monitored by a prescription database., Method: By means of a prescription database (OPED), the use of antidepressants from 1991 to 1993 in Odense, Denmark, was analysed., Results: The 1-year prevalence of antidepressant use increased significantly from 1.60% to 2.00%, which still is below the claimed 1-year prevalence of depression of at least 5%. The increase was mainly due to a rapidly increasing use of the newer antidepressants, accompanied by a moderate decline in the use of older antidepressants (mainly tricyclic antidepressants). The patterns of antidepressant use were very polymorphic, with about 5% being on continuous use for all 3 years and groups of each 20-30% being treated with: (1) several series or (2) one series or (3) only by one prescription. The share of patients presenting only one prescription (20%) was the same for older and newer antidepressants. Likewise, the rate of shifts from older to newer antidepressants or vice versa was the same (7% vs 6%). The duration of treatment did not differ much between older and newer antidepressants. Relative to the defined daily dose (DDD), the older antidepressants were given in much lower doses (median 0.63 DDD) than the newer antidepressants (median 1.05 DDD)., Conclusion: It is concluded that many depressed patients are still not receiving antidepressant treatment and that the claimed better adverse effect profile of the newer antidepressants was not clearly reflected in their use.

Objective: Concurrent use of multiple drugs (polypharmacy, PP) may cause health risks such as adverse drug reactions, medication errors and poor compliance. The objective of this study, based on data from a prescription database, was to evaluate estimators of PP in the general population., Methods: Data were retrieved from Odense Pharmaco-epidemiological Database (OPED) and consisted of all prescriptions in 1994 from a 10% random sample of drug users (n = 26,977) in the county of Funen, Denmark. For each prescription, the period of consumption was calculated by setting the duration of treatment to equal the amount of drug purchased, as measured in defined daily doses (DDD), thereby assuming a daily intake of one DDD. PP was defined as overlapping periods of consumption for different drugs. A Venn diagram was used to illustrate and compare this estimator of PP with two other indicators of multiple-drug use: the number of drugs purchased in 3 months and the mean number of drugs used in 1 year. A receiver operating curve (ROC) was used to evaluate the possibility of predicting episodes of PP from the number of drugs purchased in 3 months., Results: The proposed estimator of PP was robust towards changes in DDD. On an average day in 1994, the prevalence of PP was 9.9% and the standard deviation (SD) between days was 0.3%. Two to four drugs (minor PP) were used by 8.7% of the population (SD, 0.2%) and five or more drugs (major PP) by 1.2% (SD, 0.1%). The number of individuals displaying PP for the first time in 1994 stabilised after approximately 6 months, resulting in an incidence of major PP of 0.2% and of minor PP of 1.2% per month. For individuals exposed to PP, the median number of days of exposure was 61 and 10.5% were exposed for more than 350 days of the year. Purchase of five or more drugs in the first 3 months of 1994 predicted episodes of major PP in the same year with a positive predictive value of 80%., Conclusion: Epidemiological measures of multiple drug use can be estimated from data in a prescription database. From a conceptual point of view, an estimator based on the number of simultaneously used drugs (calculated from the date of purchase and the number of DDD) is preferable, but the number of drugs purchased in a 3-month period may also be a useful estimator.

Objective: To elucidate potential problems concerning the use of antidepressants (AD) in general practice., Design: Cross-sectional, descriptive interview study., Setting: General practices, Odense, Denmark., Subjects: Random sample consisting of 98 AD users from 12 general practices., Main Outcome Measures: Indication for AD treatment, justification of the treatment, duration of AD treatment, daily dose of AD, side effects, Hamilton depression rating, WONCA score., Results: The primary indication for AD treatment was depression (72 patients), partly regular depression (therapeutic/prophylactic treatment) (n = 39), partly depressive tendencies (n = 32) (1 unknown). Median treatment duration was 3 years; 25% had been in treatment for more than 10 years. The general practitioners judged the treatment problematic/unacceptable in 23 cases, largely because of uncertain indication or because other or no treatment was considered better for the patient. The daily doses of AD were generally low. Side effects were modest. The patients often had a relatively high depression score and poor status according to the WONCA-scale., Conclusions: The use of low doses, long duration of treatment, and uncertainty about the relevance of the treatment are important features of the use of AD by general practitioners. There seems to be a discrepancy between the use of AD in general practice and the scientifically-based recommendations.

Quinidine is a very potent inhibitor of CYP2D6, but the role of the enzyme in the biotransformation of quinidine has only been investigated in a single in vitro study and in two small in vivo experiments, with contradictory results. The present investigation was designed to present definite evaluation of whether quinidine is metabolised by CYP2D6. Eight poor metabolizers (PM) and 8 extensive metabolizers (EM) of sparteine each took one oral dose of 200 mg quinidine. In the EM, the total clearance, the clearance via 3-hydroxylation and the clearance via N-oxidation, were 33, 3.7 and 0.23 l.h-1, respectively. In the PM, the corresponding values were 29, 3.1 and 0.18 l.h-1, respectively. There were no statistically significant differences between EM and PM in any of these pharmacokinetic parameters. It is concluded that CYP2D6 is not an important enzyme for the oxidation of quinidine.

1 A prescription database study was conducted to describe the out-patient utilization of neuroleptics in the Odense area (207,000 inhabitants) during a period of 1 year. 2 Neuroleptic drug use is widespread, the period prevalence being 2.45% of the population. 3 The prevalence increases with increasing age. Fifteen percent of the population aged 90 years or more received neuroleptic drugs in spite of the many warnings against side effects in the elderly. 4 Estimated daily doses of neuroleptics were considerably lower than the Defined Daily Dose, probably as a reflection of many neuroleptics being prescribed to non-psychotic patients, in whom lower doses are used. 5 For perphenazine, a comparison of estimated daily doses from this study with doses from patients whose treatment had been adjusted by plasma concentration monitoring showed that generally much lower doses were used by patients included in this study.

A prescription database analysis was conducted to describe the users of antidepressants outside hospitals in the Odense area (207,000 inhabitants) during one year. In total, 1.62% (N = 3360) of the population used antidepressants. Women and users aged over 70 years constituted a disproportionately large part. Seventy-five percent of the patients used tricyclic antidepressants. The estimated daily doses for the tricyclic antidepressants were generally low, the third quartile being less than 100 mg daily. The low doses may be due to antidepressants being used on other indications than depression or that a considerable number of the patients are not given a sufficient dose.

The consumption of benzodiazepines and potent analgesics by old age pensioners and early retirees in Odense who had the right to receive medicine free-of-charge was accounted for where the month of March 1990 was concerned. Approximately 26% received financial support for benzodiazepines, 13% for analgesics while further 6% received support for both benzodiazepines and analgesics. The majority of the users were over 60 years and there twice as many women as men. No significant differences were observed in the sex and age distributions between the groups of pensioners who received benzodiazepines and/or analgesics and the group which received only other medicine. Both the direct and the indirect expenses are discussed. Furthermore, it is concluded that, in some of the pensioners, over-consumption is involved and that it is again necessary to emphasize the indications for prescription of these preparations.