Introduction
Safe, effective pharmacotherapy is one of the greatest challenges in clinical geriatrics. Special considerations are necessary when prescribing drugs (see Table 6-1). The elderly have many chronic disorders and consequently use more drugs than any other age group. Their diminished physiologic reserves can be further depleted by effects of drugs and acute or chronic disease. Aging alters pharmacokinetics and pharmacodynamics, affecting the choice, dose, and dosing frequency of many drugs. Pharmacotherapy may also be complicated by an elderly patient's inability to purchase or obtain drugs or to comply with drug regimens.
In the USA, about two thirds of persons >= 65 years use prescription and over-the-counter (OTC) drugs; this age group accounts for about one third of all prescription drug use. Women use more drugs than men, especially psychoactive and antiarthritic drugs. At any time, an average elderly person uses four to five prescription drugs and two OTC drugs and fills 12 to 17 prescriptions a year. The frail elderly use the most drugs. Drug use is greater in hospitals and nursing homes than in the community; typically, a nursing home resident uses seven or eight drugs.
The type of drug used most often by the elderly varies with the setting. Community dwellers use analgesics, diuretics, cardiovascular drugs, and sedative-hypnotics most often, whereas nursing home residents use antipsychotics and sedative-hypnotics most often, followed by diuretics, antihypertensives, analgesics, cardiovascular drugs, and antibiotics. According to some surveys, psychoactive drugs are prescribed for 65% of nursing home patients and for 55% of residential care patients; 7% of patients in nursing homes use three or more psychoactive drugs concurrently.
Appropriateness (the potential benefits of a drug outweigh the potential risks) should guide therapy. Determining appropriateness requires an evaluation of such potential benefits and risks. Many drugs benefit the elderly, and some can save lives--eg, antibiotics and thrombolytic therapy for acute illness. Oral hypoglycemic drugs can improve independence and quality of life while controlling diabetes. Antihypertensive drugs and influenza vaccines can help prevent or decrease morbidity. Analgesics and antidepressants can control debilitating symptoms. However, adverse effects of many drugs are more common and serious in the elderly.
Polypharmacy (concurrent use of many drugs) alone is not an accurate measure of appropriateness of therapy because the elderly often have many disorders requiring treatment; however, it may reflect inappropriate prescribing. Many elderly patients in hospitals and nursing homes routinely receive drugs that are not essential (eg, sedative-hypnotics, analgesics, histamine [H2] blockers, antibiotics, laxatives) and can cause harm, directly or through interactions. A thorough review of drugs can often reduce the number of drugs used and, according to limited data, improve patient outcomes.
Underuse of some drugs is also a significant problem among elderly patients. For example, antidepressant use in nursing homes is low compared with the high prevalence of depression. Also, the dose of antidepressants often is too low and duration of therapy too short. Drugs for incontinence and preventive treatments (eg, glaucoma drugs, influenza and pneumococcal vaccines) are also underused.
Patient and caregiver issues: Increasingly, elderly patients are aware of their diagnoses and the drugs they use for treatment; however, many need to be encouraged to bring health problems and potential drug-related problems to the attention of their physician or caregiver. In particular, patients should be asked to report their use of all drugs (eg, prescription and OTC drugs, vitamins, nutritional supplements) and to report any changes at each visit. Periodically, they should be asked to bring their drugs to the office for review and for comparison with the drug record. The physician should review and update the treatment regimen at each visit. While doing so, the physician can ask about adherence (compliance). When adherence appears to be deficient, efforts should be made to simplify the regimen and to suggest useful aids to enhance adherence (eg, drug calendars, drug dispensers). The physician should also discuss how drugs should be taken (eg, with or without food, route of administration), their mechanism of action, important adverse effects, and appropriate storage. Patients should recognize the role of the pharmacist as a member of the health care team and as a resource for information. The time devoted to communicating with patients about drugs and their usage builds trust and enhances overall patient care.
|
