Polypharmacy and the Geriatric Patient

doi:10.1016/j.cger.2007.01.002

Clinics in Geriatric Medicine

Volume 23, Issue 2, May 2007, Pages 371-390

https://doi.org/10.1016/j.cger.2007.01.002 Get rights and content

The older adult population is increasing and with it, the risk of polypharmacy. Multiple physicians treating one patient, increasing comorbidities, and an increase in the variety of drugs available contribute to the adverse effects of polypharmacy on the elderly patient. Application of Beers criteria, appropriate therapeutic drug monitoring, and careful, periodic review of the patient's medication list will assist with preventing the sometimes lethal complications of polypharmacy.

Section snippets

Adverse drug events and drug–drug interactions in the elderly

ADEs in the elderly account for approximately 10% of emergency department visits and up to 10% to 17% of hospital admissions [8], [9], [10]. In a 1-year study of ambulatory older adults, the overall rate of adverse drug events was 50.1 per 1000 person-years [11]. Of the 1523 ADEs recorded in this study, 38% were considered serious, life threatening, or fatal. Risk factors for ADEs in the geriatric population include polypharmacy, multiple comorbid conditions, prior ADEs, and dementia [12].

Drug response and pharmacokinetics in the elderly

Alterations in neurologic, cardiovascular, pulmonary, hepatic, renal, immunologic, and endocrine function increase sensitivity to drug effects in the elderly [16]. For example, elderly patients may experience exaggerated responses to centrally acting drugs, such as barbiturates, opioids, cyclic antidepressants, benzodiazepines, and central α-agonists [17]. In addition, older adults are less able to regulate body temperature, making them more sensitive to drug-induced changes in thermoregulation

Acquired long QT syndrome

With the effects of aging, multiple comorbidities, and polypharmacy, elderly patients are at significant risk for acquired prolongation of the QT interval. In one retrospective cohort study of 4.8 million patients, over 4.4 million prescriptions for QT-prolonging drugs were filled. Of these 4.8 million patients, 9.4% were concomitantly prescribed another medication that either prolonged the QT itself, or inhibited the metabolism of the QT-prolonging drug. Twenty-two percent of the patients

Warfarin

There are many conditions for which elderly patients might be prescribed oral anticoagulation therapy (OAT). Despite the risk associated with conditions such as venous thromboembolism, pulmonary embolism, and ischemic stroke, many physicians are reluctant to use OAT in the elderly population [29] ADEs from OAT negatively impact quality of life. Hanlon and colleagues [30] examined the incidence and predictors of preventable ADEs in frail elderly persons after hospital discharge. Overall, 33% of

Anticholinergics

Anticholinergic toxicity is common in older adults as they are more frequently prescribed these medications, with 11.3% of those 65 years of age and older on an anticholinergic drug compared with 3.8% of younger adults [42]. Ness and colleagues [43] reported that 27.1% of veterans 65 years or older at a primary care clinic were taking anticholinergic medications. Blazer and colleagues [44] found that almost 60% of nursing home residents, and 23% of ambulatory patients, received medications with

Sedative drugs

As a consequence of the pharmacokinetic and pharmacodynamic changes previously described, older adults are more susceptible to the sedative effects of medications. Medical conditions such as osteoarthritis, back pain, depression, and insomnia are often treated with medications that result in sedation. A Swedish survey found that one third of elderly persons living in nursing homes were prescribed three or more potentially sedating psychotropic drugs [55]. Drugs such as opioids, benzodiazepines,

Summary

The older adult population is increasing, and with it, the risk of polypharmacy. Multiple physicians treating one patient, increasing comorbidities, and an increase in the variety of drugs available contribute to the adverse effects of polypharmacy on the elderly patient. Application of Beers criteria, appropriate therapeutic drug monitoring, and careful, periodic review of the patient's medication list will assist with preventing the sometimes lethal complications of polypharmacy.

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The elderly population is affected by chronic diseases and lifelong medication. The American Geriatrics Society (AGS) Beers Criteria is a comprehensive approach to medication usage in the older population to reduce potentially inappropriate medication (PIM) use. The purpose of this study was to assess the usage of PIMs in elderly patients upon discharge from tertiary care hospital settings in Riyadh, Saudi Arabia, using the AGS Beers Criteria 2019.
The data was obtained from the medical records of 1237 patients (>65 years) who were discharged from medical or surgical wards at two hospitals affiliated with King Abdulaziz Medical City. The data was analyzed to determine the prevalence of PIM prescription, and the proportional odds of the independent factors influencing outcomes were estimated using ordinal regression analysis for criteria 1 and 2, while Binary regression analysis was conducted for criterion 3.
There were approximately equal numbers of male and female participants in our study (male: 50.8 % vs. female: 49.2 %). One-third of the patients were above the age of 80 years, with 41 % being between the ages of 70 and 80 years. Moreover, almost 70 % of the samples had chronic illnesses. The overall prevalence of PIMs was 29.2 %, with 11 % of PIMs to be avoided in elderly patients and 17 % to be used with caution in the elderly, while disease-specific PIMs were identified in 1.2 % of the patients. The most common PIM class was proton pump inhibitors (44.41 %), and patients discharged from the surgical unit were more likely to be prescribed PIMs. Proton pump inhibitors (44.41 %) were the most inappropriately prescribed drug class, and patients discharged from the surgical unit were more likely to be prescribed PIMs.
The study noticed that male gender, the presence of multiple diseases, and obesity are associated with more than one PIM prescription. There is a need to streamline the surgical department’s prescription procedure to eliminate prescription disparities. Prescription monitoring is recommended to avoid medication errors, particularly in patients who are taking multiple medications.
Polypharmacy in Older Adults
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Alcohol use disorder among aging women is rising at unprecedented rates. Postmenopausal drinkers may be especially at risk for alcohol use disorder (AUD)-related problems for numerous reasons such as: metabolic specificities due to aging process, overall longer life expectancy, facing losses leading to grief and depression, etc. Furthermore, age and gender differences may potentially affect the time course of medication absorption, distribution, metabolism, and excretion. Moreover, current researches on interventions and treatments that aim to reduce AUD or to prevent its occurrence in middle-aged and elderly women are limited, and limited number of medication treatments has been approved by the US FDA. Here, we provide an overview by evaluating medications’ efficacy, side effects, and contraindications focusing on age and gender differences. Also, we discuss emerging themes and different pharmacotherapies with the aim to identify optimal gender-specific pharmacotherapy options in postmenopausal patients.
Benefit of the geriatric mobile unit's intercession on the quality of medical prescriptions for the elderly: Past year assessment
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Notre unité d’évaluation gériatrique pluriprofessionnelle intervient au domicile de personnes âgées de plus de 75 en risque de perte d’autonomie. Une de ses missions est d’améliorer la prise en charge médicamenteuse. L’objectif de ce travail a été de montrer l’intérêt de l’intervention du gériatre et du pharmacien de l’équipe sur la qualité des prescriptions médicamenteuses des personnes âgées. Une conciliation médicamenteuse des traitements et une réévaluation de la pertinence des prescriptions a été systématiquement réalisée. Les problèmes liés à la thérapeutique médicamenteuse ont été répertoriés et classés selon les critères d’interventions pharmaceutiques définis par la Société française de pharmacie clinique (SFPC). Sur 181 patients, 86,2 % avaient au moins une modalité de prescription sous-optimale. Au total, 462 propositions de modifications, soit en moyenne 2,9 ± 1,9 par patient : 204 arrêts, 166 ajouts, 58 adaptations posologies, 21 suivis thérapeutiques et 13 modalités d’administration. Ce travail de réévaluation des prescriptions a permis de développer entre l’unité et les professionnels libéraux une communication axée sur l’optimisation thérapeutique et de diffuser des recommandations de bon usage du médicament chez le sujet âgé.
Our multidisciplinary geriatric mobile unit works in behalf of the frail elderly people, aged at least 75, who are in loss of self-reliance. One of its main aims is so optimize medical prescriptions. The purpose of this study was to show the benefit of geriatrician and pharmacist interventions over the quality of medical prescriptions for the elderly. Medication reconciliation of treatment and reassessment of the appropriateness of the prescriptions was systematically carried out. The problems related to drug therapy have been listed and classified according to the criteria of pharmaceutical interventions defined by the French Society of Clinical Pharmacy (SFPC). Out of 181 patients, 86,2% had potentially an inappropriate or sub-optimal prescription. Finally, 462 optimizations were proposed (2.9 ± 1.9 by patients): 204 withdrawals, 166 additions, 58 dosage adaptations, 21 therapeutic follow-ups and 13 modalities of administration. This reassessment of the prescriptions allowed to develop between our geriatric mobile unit and the liberal professionals a communication focused on the therapeutic optimization and to spread recommendations on the proper use of drugs in the elderly population.
Medication-Related Dizziness in the Older Adult
2019, Dizziness and Vertigo Across the Lifespan
Dizziness is highly prevalent among adults aged 65 years and older. Normal aging does not cause dizziness, but other factors including comorbid conditions, drug-related problems, and polypharmacy predispose older adults to dizziness. This article provides an overview of the available literature regarding medication-related dizziness in older adults. We searched MEDLINE/PubMed, CINAHL, and PsycINFO from January 1996 to April 2017 to identify potential studies of drug-induced dizziness in older adults for inclusion in this review. Evidence from the available literature clearly implicates medications as a risk factor for dizziness in the older adult population. The following classes of medications were individually associated with dizziness: antihypertensives, benzodiazepines, hypnotics, anxiolytics, and antiepileptics. Use of three or more medications (polypharmacy) for all classes considered is associated with an increased risk of dizziness. Fortunately, medications are a modifiable risk factor for dizziness. Discontinuation of medications in older adults who are on complex drug regimens to manage multiple chronic diseases can be challenging, particularly when multiple prescribers are involved. Pharmacologic treatment with drugs such as meclizine is often recommended to manage dizziness in older adults. Caution is advised, however, when prescribing meclizine for older adults because of its anticholinergic properties. In conclusion, medication-related dizziness is an important consideration in older adults. Performing a medication history and adjusting the medication regimen may help prevent or resolve medication-related dizziness.
Pain, aging and dementia: Towards a biopsychosocial model
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Citation Excerpt :
These findings call into question the usefulness of NPS as indicators of pain (van Dalen-Kok et al., 2015). With such high prevalence rates, the specificity of these symptoms for pain must necessarily be low, and their responsiveness to pain management may signal a nonspecific sedative effect of analgesics (Hayes et al., 2007) rather than pain relief per se. This is important because attributing NPS to pain may lead to overtreatment of pain and undertreatment of NPS.
Dementia is a progressive disease associated with irreversible impairment and loss of cognitive abilities. About half of older people with dementia experience pain. In this paper, we propose that pain in older people with dementia can be conceptualized as the final result of the interaction of three heterogeneous phenomena, pain, aging, and dementia, which are created and influenced by the interactions of predisposing, lifelong, and current biopsychosocial factors. We review pain assessment in people with dementia using both self-report and observational/behavioral measures. We then review the biological/sensory, psychological (cognitive and affective) and social dimensions of pain in dementia. The available data suggest that dementia does not impact pain threshold or tolerance. To date, there is little research on the social dimension of pain in dementia. Changes in the affective domain in response to experimental pain have been contradictory with evidence supporting both increased and decreased unpleasantness and emotional responsiveness in people with dementia compared to healthy controls. Clinically, depression is a significant burden for older people with dementia and chronic pain. The relationship between pain and other neuropsychiatric symptoms is controversial, and there is insufficient evidence on which to base conclusions. Some of the most important dementia-related changes may arise in the cognitive domain, including impairments of semantic and episodic memory for pain, executive function, and pain anticipation. Changes in brain activation and interconnectivity support many of these conclusions. Despite methodological limitations, we conclude there are compelling preliminary data to support a biopsychosocial framework of pain and dementia. Future research directions, especially the need for improved assessment tools, are highlighted.

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Polypharmacy and the Geriatric Patient

Section snippets

Adverse drug events and drug–drug interactions in the elderly

Drug response and pharmacokinetics in the elderly

Acquired long QT syndrome

Warfarin

Anticholinergics

Sedative drugs

Summary

Mayo Clin Proc

Mayo Clin Proc

Am J Geriatr Pharmacother

Ann Emerg Med

Am J Geriatr Pharmacother

Am J Emerg Med

Am J Med

J Am Coll Cardiol

Am J Cardiol

Pharmacol Ther

Chest

Lancet

Am J Geriatr Pharmacother

Clin Ther

Recent patterns of medication use in the ambulatory adult population of the United States

JAMA

Increasing use of medicines in elderly persons: a five-year follow-up of the Kuopio 75+ Study

Eur J Clin Pharmacol

Explicit criteria for determining potentially inappropriate medication use by the elderly. An update

Arch Intern Med

Updating the Beers criteria for potentially inappropriate medication use in older adults

Arch Intern Med

Adverse drug events in high risk older outpatients

J Am Geriatr Soc

Adverse reactions as a cause of hospital admissions in the aged

Drugs Aging

Incidence and preventability of adverse drug events among older persons in the ambulatory setting

JAMA

Important drug-drug interactions in the elderly

Drugs Aging

Incidence and risk of potential adverse drug interactions in the emergency room

Resuscitation

Drug dosage in the elderly. Is it rational?

Drugs Aging

Pharmacokinetic and pharmacodynamic changes in the elderly. Clinical implications

Clin Pharmacokinet

Hyponatremia associated with selective serotonin-reuptake inhibitors in older adults

Ann Pharmacother

Appendix A. P450 tables

QT dispersion increases with aging

Ann Noninvasive Electrocardiol

The cardiac hERG/IKr potassium channel as pharmacological target: structure, function, regulation, and clinical applications

Curr Pharm Des

Torsade de pointes in patients on chronic amiodarone treatment: contributing factors and drug interactions

Isr Med Assoc J

Pentamidine-induced long QT syndrome and block of hERG trafficking

J Pharmacol Exp Ther

Corrected QT intervals in newly admitted geriatric psychiatric patients: an examination of risk factors

Can J Psychiatry

Electocardiographic principles