Drug therapies in older adults (part 1)

Abstract

Prescribing for older adults represents a signifi cant challenge as the UK population ages. Physiological decline and the rising prevalence of frailty increase the likelihood of altered pharmacodynamics and pharmacokinetics, suboptimal prescribing and adverse effects among this growing cohort of the population. In the fi rst of two articles, we begin by considering these issues and posit four key questions which should be considered when prescribing for older adults. Does this agent refl ect the priorities of the patient? Are there alternatives -with greater effi cacy, effectiveness or tolerability -that might be considered? Are the dose, frequency and formulation appropriate? How does this prescription relate to concurrent medication? We also describe current drug therapies in two disease states with a predilection for older adults: Alzheimer's disease (AD) and osteoporosis. Using these examples we highlight the limitations of evidencebased medicine and guidelines in this cohort of the population, illustrating the reliance on sub-group analysis to demonstrate the effi cacy of drug therapies for older adults in osteoporosis and the underutilisation of appropriate treatments for patients with AD as a result of fl awed guidelines.

Dosage Adjustments Related to Young or Old Age and Organ Impairment

“…Geriatricians often think of the elderly as falling into 3 categories, the “young old” aged 65 to 74, the “old old” aged 75 to 84, and the “frail elderly” aged 85 and above. More than half of the elderly have 3 or more chronic medical conditions, with the number of conditions rising with age, and they commonly take from 4 to 9 or more medications and over‐the‐counter products including herbal products and dietary supplements daily . Managing patients with multiple chronic conditions requires careful and judicious balancing of the risks, benefits, and costs of available therapies.…”

“…Consequently, when evidence‐based clinical guidelines are developed based on the results of large‐scale clinical trials, the elderly are systematically underrepresented in the data on which the guidelines are based. Results obtained in middle‐aged people who for the most part are healthy except for the condition under study cannot simply be extrapolated to the frail elderly with multiple comorbid conditions, although it is the elderly population that is most likely to have chronic medical conditions requiring treatment …”

“…More than half of the elderly have 3 or more chronic medical conditions, with the number of conditions rising with age, and they commonly take from 4 to 9 or more medications and over-thecounter products including herbal products and dietary supplements daily. 8 Managing patients with multiple chronic conditions requires careful and judicious balancing of the risks, benefits, and costs of available therapies. It is frequently necessary to forgo optimal treatment for 1 condition in order to avoid worsening another or inducing serious drug interactions and side effects.…”

“…Results obtained in middle-aged people who for the most part are healthy except for the condition under study cannot simply be extrapolated to the frail elderly with multiple comorbid conditions, although it is the elderly population that is most likely to have chronic medical conditions requiring treatment. [8][9][10]34 Results obtained in middle-aged people cannot be extrapolated to the elderly for several reasons. The elderly frequently have multiple comorbid conditions and are taking multiple medications.…”

Yaşlılarda doğru ilaç kullanımı

“…Buna karşıt olarak, kırılganlık, "bireyde çoklu organ sistemlerinde meydana gelen progresif azalmanın fonksiyon kaybına, fizyolojik rezervin azalmasına ve hastalıklara ve ölüme olan korunmasızlığın artmasına neden olan bir süreç" biçiminde tanımlanmaktadır (11). Son yıllarda bu iki tanım arasındaki farkın dikkate alınması, aslında yaşlı bireylerden çok kırılgan yetişkinlerin ayırdına varılmasına neden olmuştur.…”